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Surgically Treated Severe Odontogenic Infections: A Large Cost to the United States Hospital System and Patients

Article Information

Timothy W. Neal DDS*, Yousef Hammad DMD, Brian R. Carr DMD, Thomas Schlieve DDS MD

Department of Surgery, Division of Oral and Maxillofacial Surgery, UT Southwestern/Parkland Memorial Hospital, 5323 Harry Hines Boulevard MC 9109, Dallas, TX 75390-9109, USA

*Corresponding Author: Timothy W. Neal, DDS, UTSW Medical Center, 5323 Harry Hines Boulevard, Dallas, TX, 75390, USA

Received: 04 November 2021; Accepted 11 November 2021; Published: 22 November 2021

Citation:

Timothy W. Neal, Yousef Hammad, Brian R. Carr, Thomas Schlieve. Surgically Treated Severe Odontogenic Infections: A Large Cost to the United States Hospital System and Patients. Dental Research and Oral Health 4 (2021): 085-090.

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Abstract

Objectives
This purpose of this study was to analyze the cost of surgically treated severe odontogenic infections to both the patient and the hospital system.

Materials and Methods
This retrospective chart review assessed data of patient hospital charts surgically treated for severe odontogenic infections in the operating room and admitted for greater than one day. Hospital charts of consecutive inpatients admitted from the ED to the University of Texas Southwestern Medical Center and Parkland Memorial Hospital for treatment from January 1st 2016 to December 31st 2020, were reviewed. Patients with infections of non-odontogenic origin were excluded. The specific outcome measures included total hospital stay cost, amount not collected, hospital charity adjustments, insurance type, length of stay, number of infected spaces, number of operating room visits, imaging ordered, and preadmission antibiotics.

Results
Data from 144 consecutive hospital charts were analyzed. The total billed cost of stay across all study years was $6,888,326.52, the average billed cost per hospital stay was $47,835.60, and the amount not collected was $2,864,857.82. Of the total billed cost, $2,107,692.15 was covered by hospital charity. Only $777,276.43 (11.3%) of the total $6,888,326.52 billed was collected by the hospital.

Conclusions
Patients that are treated for severe odontogenic infections incur a large hospital bill that could have been avoided. Often, a very small percentage of this bill is collected by the hospital.

Keywords

Infection, Public health, Hospital dentistry, Cost

Infection articles; Public health articles; Hospital dentistry articles; Cost articles

Article Details

1. Introduction

Dental related emergency department (ED) visits account for about 4.3% of all ED visits in the United States annually, and a steady increase has been observed over time [1,2]. From 2001 to 2008 the national estimates for total ED visits for all conditions increased 13%, while the number of dental related ED visits increased more than 41% [3]. Patients present to the ED with a variety of dental conditions, the most common being dental caries [4]. Often, hospitals are not equipped to provide conservative dental treatment, and this leads to management with prescription antibiotics and analgesics instead of source control. It has been reported that 90% of dental related ED visits result in prescription medication instead of dental treatment [3].

Untreated dental caries may progress to severe odontogenic infections (SOI) with variable time and severity depending on several host and bacterial virulence factors. These SOIs, if left untreated, may lead to life threatening conditions such as airway embarrassment, mediastinitis, sepsis, cerebrospinal abscess, and cavernous sinus thrombosis [5]. Rarely, these infections can lead to death. The pathogenesis of SOIs usually begins with localized infection of the periapical region or vestibule, and when neglected, these infections follow the path of least resistance and spread to fascial spaces of the head and neck. In the early phase of the disease process, patients typically have dental pain at which point conservative treatment may have prevented further progression. Consistent dental maintenance and procedures can be costly and may be a reason why many patients present to the ED with dental complaints. In cases when infections are severe enough to warrant admission and treatment in the OR, greater cost is incurred to the hospital system and the patients, which could have been prevented with routine maintenance and early conservative care. The purpose of this study was to analyze the cost of surgically treated SOIs to both the patient and the hospital system.

2. Materials and Methods

This retrospective chart review was designed to assess data of patient hospital charts admitted for SOIs and surgically treated in the operating room (OR). Institutional review board exemption was granted by the University of Texas Southwestern (UTSW). A database search of all patients treated in the operating room for odontogenic infections was completed. Severe odontogenic infections, as defined by this study, are those that involve fascial spaces of the head and neck requiring drainage in the operating room setting and admission for intravenous antibiotics. The decision to admit and treat in the OR was made by the attending surgeon based on clinical presentation, history, and laboratory results. Consecutive hospital charts were reviewed of inpatients admitted from the ED to the UTSW Medical Center and Parkland Memorial Hospital from January 1st 2016, to December 31st 2020. The inclusion criteria included patients surgically treated in the operating room for SOIs and admitted greater than one hospital day. Patients were excluded from the study if they had infections of non-odontogenic origin. The specific outcome measures included total hospital stay cost, amount not collected, hospital charity adjustments, insurance type, length of stay, number of infected spaces, number of operating room visits, imaging ordered, and preadmission antibiotics. The amount not collected is the amount that was left unpaid by the patients after adjustments and designated in the financial record as a “bad account.” Demographic data was also collected.

3. Results

3.1 Demographics

This retrospective chart review consisted of 144 patient hospital charts that met the inclusion criteria. The median age was 40 years (range 16-81) with a male to female ratio of 5:4 (79:65). Table 1 provides a summary of demographic data as well as comorbidities.

Variable

n = 144

% of total n

Male

79

54.9

Female

65

45.1

Current smoker

53

36.8

Diabetic

33

22.9

HIV seropositive

9

6.3

Hematologic malignancy

2

1.4

Table 1: Demographics and comorbidities of all hospital charts reviewed.

3.2 Hospital stay characteristics

Each patient received at least one computed tomography (CT) scan during the hospital stay. The average number of spaces affected was 2.4 (range 1-8).  The average length of stay was 5.1 days (range 2-46). Seven patients required advanced airway and intensive care unit stay following surgery for an average of 7.4 days (range 2-21).

3.3 Preadmission antibiotics

Data regarding antibiotic treatment prior to presentation to the ED was collected. Of the 144 patient charts reviewed, sixty-two (43.1%) had received antibiotics prior to presentation. Of the sixty-two patients, forty (65%) received penicillin, eighteen (29%) received clindamycin, and four (6%) received other antibiotics or a combination.  

3.4 Patient insurance characteristics

Residents of Dallas County are eligible for financial assistance based on income in relation to federal poverty income level guidelines and household size. Table II shows the insurance types of the study population. Patients with no income are eligible to receive free care and those with low income are eligible to receive care at a substantially reduced cost. Insurance type was categorized as self-pay, Medicare/Medicaid, charity, and private.

Insurance Type

n = 144

% of total n

Self-Pay

65

45.1

Medicare/Medicaid

24

16.7

Charity

33

22.9

Private

22

15.3

Table 2: Insurance types of all hospital charts reviewed.

3.5 Cost summary

The total billed cost of stay across all study years was $6,888,326.52, the average billed cost per hospital stay was $47,835.60, and the amount not collected was $2,864,857.82. Of the total billed cost $2,107,692.15 was covered by hospital charity. Insurance adjustments accounted for $1,138,500.12 of the total billed. A total of $777,276.43 (11.3%) was collected by the hospital over the study period. Table III provides a cost summary for each year included in the study. The percentages of the total billed amounts that were collected by the hospital per year were: 17.1% (2016), 6.1% (2017), 14.2% (2018), 3.9% (2019), and 16.2% (2020).

Variable

2016

2017

2018

2019

2020

Total billed cost

$966,527.82

$1,503,482.69

$1,408,722.98

$1,343,745.78

$1,665,847.25

Amount not collected

$154,529.95

$1,039,787.09

$697,397.96

$459,992.18

$513,150.64

Hospital charity

$271,762.42

$288,579.88

$245,335.32

$656,338.56

$645,675.97

Insurance Adjustments

$375,019.71

$84,155.91

$265,762.10

$176,054.51

$237,507.89

Table 3: Cost summary for each year included in the study.

4. Discussion

The purpose of this study was to analyze the cost of surgically treated odontogenic infections to both the patient and the hospital system. Of the total $6,888,326.52 billed across all study years, only $777,276.43 was collected (11.3%). Few studies have investigated the cost of surgically treated odontogenic infections. In a study of forty-two patients with odontogenic infections treated surgically from 2005 to 2008, Jundt and Gutta reported a total of $749,382 billed and $70,123 (9.4%) collected [6]. Christensen and colleagues reported a total of $5,422,854 billed and $1,528,869 collected (28.2%) in a study of 318 patients from 2001 to 2011. This study included patients treated for odontogenic infections outside of the operating room (clinic, emergency, or combination of both) [7]. In a study by Ahmad and colleagues of 327 patients admitted for management of acute odontogenic infections from 2003 to 2010, more than $10,000,000 was billed [8]. However, this study did not include the amount collected by the hospital. Previous studies have shown that many factors are significant predictors of increased hospital bills including location of treatment, length of stay, length of ICU stay, return trips to the OR, and type of antibiotic regimen [7,9]. The average length of stay in our study was 5.1 days and the average length of ICU stay was 7.4 days.  Ten patients required return trips to the OR, and an average of 2.4 fascial spaces were involved. These factors were similar to previous studies with the exception of ICU stay duration, the average of which is elevated due to a patient with bilateral deep neck abscesses who required tracheostomy and extended ICU stay [10-12]. The demographic characteristics of our study population were similar to previous studies, with the exception of higher tobacco use and prevalence of diabetes [13,14]. The average cost of stay billed to the patient by the hospital was $47,835.60 which is comparable to findings of $48,351 by Gams et al [15]. In our study population 45.1% of patients were categorized as self-pay. For an uninsured patient, a bill of this magnitude is a significant financial burden that could have largely been avoided with preventative care. The total cost of hospital management of odontogenic infections is not fully elucidated by this study, which is limited by its retrospective design. The total cost did not account for the cost incurred from follow up visits, treatment by incision and drainage in the ED, and ED visits for dental pain that resulted in antibiotic treatment only. The total cost is certainly much higher with these components considered.

5. Conclusion

In conclusion, our study shows the substantial cost associated with admission and surgical treatment of SOIs. This cost is a heavy burden on the hospital system and patients. Surgical treatment of SOIs represents a significant loss of hospital revenue yearly. In patients with SOIs, it is paramount to minimize factors that are predictive of increased hospital bills. Given the preventable nature of these infections, this study highlights the importance of regular dental visits, good oral hygiene practices, and increased access to dental care in the United States.

Funding

The authors have no outside funding to report. Submission of this manuscript was supported by departmental funds.

Conflict of interest

The authors have no conflict of interest to declare.

References

  1. McCormick AP, Abubaker AO, Laskin DM, et al. Reducing the burden of dental patients on the busy hospital emergency department. J Oral Maxillofac Surg 12 (2013): 475-478.
  2. Wall T. Recent trends in dental emergency department visits in the United States- 1997/1998 to 2007/2008. J Public Health Dent 10 (2012): 216-220.
  3. Allareddy V, Rampa S, Lee MK, et al. Hospital-based emergency department visits involving dental conditions. J Amer Dent Assoc 5 (2014): 331-337.
  4. Lee HH, Lewis CW, Saltzman B, et al. Visiting the emergency department for dental problems: Trends in utilization, 2001 to 2008. Am J Public Health 14 (2012): 77-83.
  5. Pesis M, Bar-Droma E, Ilgiyaev A, et al. Deep neck infections are life threatening infections of dental origin: A presentation and management of selected cases. Isr Med Assoc J 8 (2019): 806-811.
  6. Jundt JS, Gutta R. Characteristics and cost impact of severe odontogenic infections. Oral Surg Oral Med Oral Pathol Oral Radiol 7 (2012): 558-566.
  7. Christensen B, Han M, Dillon J. The Cause of cost in the management of odontogenic infections: A demographic surgery and multivariate analysis. J Oral Maxillofac Surg 7 (2013): 2058-2067.
  8. Ahmad N, Abubaker OA, Laskin DM, et al. The financial burden of hospitalization associated with odontogenic infections. J Oral Maxillofac Surg 9 (2013): 656-668.
  9. Christensen B, Han M, Dillon J. The Cause of Cost in the Management of Odontogenic Infections 2: Multivariate Outcome Analyses. J Ora Maxillofac Surg 11 (2013): 2058-2067.
  10. Farmahan S, Tuopar D, Ameerally P, et al. Microbiological examination and antibiotic sensitivity of infections in the head and neck: Has anything changed? Br J Oral Surg 3 (2014): 632-35.
  11. Ylijoki S, Suuronen R, Jousimies-Somer H, et al. Differences between patients with or without the need for intensive care unit due to severe odontogenic infections. J Oral Maxillofac Surg 10 (2001): 867-872.
  12. Walia I, Borle R, Mehendiratta D. Microbiology and antibiotic sensitivity of head and neck space infections of odontogenic origin. J Oral Maxillofac Surg 5 (2014): 16-21.
  13. Flynn TR, Shanti RM, Levi MH, et al. Severe Odontogenic Infections, Part 1: Prospective Report. J Oral Maxillofac Surg 15 (2006): 1093-1096.
  14. Flynn TR, Shanti RM, Levi MH, et al. Severe Odontogenic Infections, Part 2: Prospective Report. J Oral Maxillofac Surg 15 (2006): 1104-1113.
  15. Gams K, Shewale J, Demian N, et al. Characteristics, length of stay, and hospital bills associated with severe odontogenic infections in Houston, TX. J Am Dent Assoc 8 (2017): 221-229.

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