A new research brief from the American Dental Association’s Health Policy Resources Center finds that an increasing number of Americans visited emergency departments (ED) for dental-related care between 2000 and 2010, as a percentage of total dental visits. ED visits for dental care increased from 1.1 million in 2000 to 2.1 million in 2010.

The increase was primarily among young adults (age 21 to 34), which the researchers hypothesize is due to a decline in dental benefits among this age group. Young adults were more likely than others to report that they could not afford dental care in the past 12 months, the brief says, and recent studies have shown that there has been a shift in the pattern of dental benefits.

“Unfortunately, the Affordable Care Act (ACA) did little to address the issue of dental utilization in emergency departments,” the brief says. The law does not mandate dental benefits for adults, and insurance plans sold through most states’ exchanges are unlikely to include dental benefits. However, pilot programs in some states have shown promise for diverting patients with dental complaints from EDs and increasing their access to dental care.

“In the coming years, advocates for oral health will have to consider other innovative ways to increase access to dental care in order to decrease dental care utilization in hospital emergency departments,” the brief concludes. “Without further interventions from policy makers, dental ED visits are likely to increase in the future, straining our health care system and increasing overall health care costs. Now more than ever, innovative solutions are needed to improve access and oral health.”

Read the brief on patients visiting emergency departments for dental care.

Carolyn Hayes, PhD, RN, NEA-BC, is associate chief nurse for Adult Inpatient and Integrative Oncology at Dana-Farber Cancer Institute and Brigham & Women’s Hospital (BWH) in Boston, MA. She is a Robert Wood Johnson Foundation Executive Nurse Fellow (2012). Here, Hayes reflects on how nurses provided quality care to patients and others traumatized by the bombing at the Boston Marathon. This is part of a series of posts for National Nurses Week, highlighting how nurses are driving quality and innovation in patient care.

I remember a brief report on television, just after the Newtown shootings, when an emergency department (ED) physician in Connecticut said his emotional pain started with his realization that his ED was not getting any victims. It clearly overwhelmed him not to be able to help. At the time I felt for him but on Monday, April 15, after the Boston Marathon bombing, I truly understood him. I, along with other highly-skilled members of the health care and support teams at Brigham & Women’s Hospital, had the privilege of making a difference for the victims of that tragic event.

That Monday, I was the operations section chief—the role designed to ensure staff, materials, supplies, and systems are in place to address whatever is occurring. On Friday the 19th, the day that Boston and surrounding towns were instructed to “shelter in place,” I was incident commander.

We saved lives and limbs in our ED that day. But we also tended to the anxiety, fear, and confusion created by an attack on our city. We addressed with patients, their families, family members of unidentified marathon victims, and ourselves, the existential gap created by the “why” of it all. We lived out what we had trained for, yet couldn’t comprehend. And we did it all as a community.

Around the country, print, broadcast and online media outlets are covering the groundbreaking work of Robert Wood Johnson Foundation (RWJF) leaders, scholars, fellows and grantees. Some recent examples:

Patient-centered end-of-life care leads to happier patients who are in less pain and whose care costs less, RWJF/U.S. Department of Veterans Affairs Clinical Scholar Jonathan Bergman, MD, and his colleagues write in the journal JAMA Surgery. Such care is already provided,  the Los Angeles Times reports, at the UCLA Health System, where urology residents are receiving education about end-of-life care, and at the West L.A. Veterans Affairs Medical Center where researchers are integrating palliative care into cancer treatment.

The current system used to evaluate the appropriateness of emergency department visits—and sometimes to deny payment—is flawed, according to a study co-authored by RWJF Physician Faculty Scholars alumna Renee Hsia, MD, MSc, because it only takes into account a patient’s discharge diagnosis (for example, acid reflux), which is often not the reason they originally presented at the ER (chest pain). The researchers warn this could have serious implications, including dissuading patients from using the ER even when their symptoms indicate that they should, United Press International reports.

Susan Wolf, JD, recipient of an RWJF Investigator Award in Health Policy Research, spoke to the Boston Globe about new recommendations from a national organization of genetics specialists that “urge doctors who sequence a patient’s full set of genes for any medical reason to also look for two dozen unrelated genetic conditions, and to tell the individual if they find any of those conditions lurking in the DNA.” All of the genetic mutations on the list are rare, but some indicate an increased risk of cancer or heart disease. In some cases, the genetic results could also indicate that the patients' blood relatives have increased risk, as well.

Around the country, print, broadcast and online media outlets are covering the groundbreaking work of Robert Wood Johnson Foundation (RWJF) leaders, scholars, fellows and grantees. Some recent examples:

The average emergency room visit costs 40 percent more than a month’s rent, according to a study led by RWJF Physician Faculty Scholar Renee Hsia, MD, MSc. The study also found the “sticker price” for emergency department care varies widely, the Washington Post Wonk Blog reports, with a sprained ankle ranging from $4 to $24,110. Among the other outlets to report on Hsia’s findings: Health Day, Bloomberg, and MSN.com. Read a post Hsia wrote for the RWJF Human Capital Blog about ambulance diversion and emergency room crowding.

RWJF Health & Society Scholar Jennifer Karas Montez, PhD, was a guest on CNN’s The Situation Room with Wolf Blitzer to comment on a recently released longevity study. Montez' research in this area has focused on longevity among women, and she found that low-educated women (especially those without a high school education) have seen declines in their life expectancy, while life expectancy for men has stayed steady or increased. The Associated Press also reported on Montez research.

Americans support government intervention in matters of public health, such as curbing obesity, U.S. News & World Report says in reporting on research conducted by Michelle M. Mello, JD, PhD, MPhil, an RWJF Investigator Award in Health Policy Research recipient. Three-fourths of respondents in a survey said they support laws that would discourage obesity in adults, with most favoring less-intrusive measures such as posting calorie counts.

Comilla Sasson, MD, MS, FACEP is an attending physician at the University of Colorado Hospital and Assistant Professor in the Department of Emergency Medicine at the University of Colorado.  Sasson was a Robert Wood Johnson Foundation (RWJF) Clinical Scholar at the University of Michigan from 2007 to 2010. Her latest study is published in the October 25th, 2012 issue of the New England Journal of Medicine.

Dead. How do you make someone “undead?” How, with just your two hands, can you prolong the time that paramedics have to restart a person’s heart? How can a normal, ordinary person make a difference and literally save a life?

We know that a person’s chances of surviving an out-of-hospital sudden heart arrest decreases by 10 percent for every one minute he/she does not get CPR (cardiopulmonary resuscitation).  I had learned about hands-only CPR in my medical training.  Hands-only CPR is where all you have to do is push hard and fast (to the tune of “Staying Alive”) at a 100 times a minute until helps arrives.

But time and time again, I cared for African-American patients in Atlanta who had laid in their families’ homes for critical minutes as their brains slowly died from a lack of blood supply from the heart.  Their hearts had stopped and no one called 911. No one placed their hands on the chest and started doing hands-only CPR.

Maybe this is just Atlanta? Is it the color of a person’s skin or is the place where he or she collapses that makes the difference?

In my Robert Wood Johnson Foundation Clinical Scholars Program (RWJCSP) at the University of Michigan (2007-2010), I learned about the importance of neighborhoods in determining a person’s health.  After wading through the literature, my a priori hypothesis was that having someone stop to provide CPR is completely dependent upon others; therefore, the neighborhood plays a large role in whether or not someone does CPR.

After consulting with my two RWJCSP alumni mentors, David Magid, MD, MPH, and Arthur Kellermann, MD, MPH, FACEP, the question became clear: What role does the racial and socioeconomic composition of a neighborhood have on an individual’s likelihood of receiving life-saving bystander CPR?

Last week, the Robert Wood Johnson Foundation (RWJF) and The Alliance for Health Reform sponsored a briefing to discuss oral health care in the United States, particularly for children and other vulnerable populations.

The discussion was co-moderated by David Krol, MD, MPH, FAAP, RWJF Human Capital Portfolio team director and senior program officer. “Oral health is an integral part of overall health,” he said. It faces the same challenges as overall health care, including “racial, ethnic, geographic disparities in disease and access to care, financing challenges, issues of determining and maintaining quality of care, and workforce controversies.” Krol said he would like to see “all conversations on health and health care… naturally include oral health.”

In 2009, preventable dental conditions accounted for more than 830,000 emergency department visits nationwide, Julie Stitzel, MA, of the Pew Center on the States’ Children’s Dental Campaign told the audience. Children were the patients for 50,000 of those visits. “There’s a real opportunity for states to save money because these visits, again, are totally preventable,” she said. “We know that getting treated in an emergency room is much more costly than the care delivered in a dental office, and states are bearing a significant share of these expenses through Medicaid and other public programs.”

Around the country, print, broadcast and online media outlets are covering the groundbreaking work of Robert Wood Johnson Foundation (RWJF) leaders, scholars, fellows and grantees. Some recent examples:

José A. Pagán, PhD, recipient of an RWJF Investigator Award in Health Policy Research and a member of the RWJF Health & Society Scholars National Advisory Committee, spoke to Senior Housing News about funding and programs from the Affordable Care Act that will benefit the senior living industry.

The Westfield Patch reprinted an article from the New Jersey Nursing Initiative (NJNI) newsletter about how the program benefited Maria Torchia LoGrippo, MSN, RN, a member of the program’s inaugural cohort in 2009. “I was truly honored and humbled when I received the scholarship,” she says. “[G]iven this amazing opportunity from the RWJF, I will be able to achieve my goal to become a nursing professor.”

The University of Texas at El Paso (UTEP) School of Nursing has received a grant from the Texas Higher Education Coordinating Board that will help train more emergency and trauma care nurses, KDBC-TV reports. The Emergency and Trauma Care Education Partnership Program will train students through August 2013. RWJF Executive Nurse Fellow Elias Provencio-Vasquez, PhD, RN, FAAN, FAANP, is dean of the UTEP School of Nursing.

A project funded in part by the RWJF Clinical Scholars program at Yale University is working to create a video game “aimed at preventing the spread of HIV among minority adolescents,” the Stamford Advocate reports. Teens can create an avatar to navigate through the game’s interactive world, facing a series of challenging situations and choices.

A team of researchers led by Investigator Award in Health Policy Research recipient Aaron Kesselheim, MD, JD, MPH, finds that only one in seven physicians and scientists (15 percent) sufficiently disclose conflicts of interest with pharmaceutical companies in published studies. “We were surprised at the relatively low number of adequate disclosures,” Kesselheim told The Scientist. “We were also surprised at the variability of the disclosures, and how some journals seemed to have very clear disclosures where some did not.” MediLexicon also reports on the findings. Read a post Kesselheim wrote for the RWJF Human Capital Blog about pharmaceutical industry marketing to medical students.

Comilla Sasson, MD, MS, is an attending physician at the University of Colorado Hospital and Assistant Professor in the Department of Emergency Medicine at the University of Colorado.  Sasson was a Robert Wood Johnson Foundation (RWJF) Clinical Scholar at the University of Michigan from 2007 to 2010.

I wasn’t even supposed to work that night. I had finished a long day of meetings, and found out at 6:30 pm that my colleague, who had called in sick twice in 40 years, had influenza and he knew it was best not to expose Emergency Department (ED) patients to it.  After he called, I remember thinking, “Well, I can just power through until 8 am. Nothing too bad happens on Thursday nights.”

The night began as many other nights do in our ED. Twenty-five of our 50 beds were taken up by inpatients who were waiting for hospital beds to open up.  The ED was completely full, with another 10 patients in the waiting room. “Another one of those nights,” I groaned to myself.  We were already on “divert” status, meaning that ambulances would bypass our hospital and go to others in town. This should be a relatively easy night, right?

Until we received the call over the dispatch radio at approximately 12:30 am: Shooting at a theater in Aurora. Hopefully the paramedics remembered we were already at capacity and took the patients elsewhere.  Nine minutes later, we received a frantic phone call from one of the policemen on scene: Multiple shooting victims and Aurora Police Department just received permission to transport patients to hospitals in the backs of police cars instead of waiting for ambulances.  That’s when we realized this was not a gang fight with one or two victims, this was something different. 

The first police car showed up at 1:06 am. We raced out to the ambulance bay and started removing patients from the back of the car. The police car looked like a crime scene, with blood splattered throughout. As we were pulling the first two victims out of the car, another police car showed up. And another. And another. In total, we received nine police cars and one ambulance within 45 minutes.  Looking out into our ambulance bay with police lights flashing, I realized, this is not like any other shooting I have been involved in. This is radically different.

Around the country, print, broadcast and online media outlets are covering the groundbreaking work of Robert Wood Johnson Foundation (RWJF) leaders, scholars, fellows and grantees. Some recent examples:

Twenty nurses from across the country have been selected as RWJF Executive Nurse Fellows for 2012, the Foundation announced this week. This diverse group will participate in a three-year, world-class leadership development program that is enhancing nurse leaders’ effectiveness in improving the nation’s health care system. Read more about the new cohort on NurseZone.com.

RWJF Health & Society Scholar Aric Prather, PhD, continues to receive media coverage for his study finding that patients’ lack of sleep could reduce the effectiveness of vaccines. Among the outlets to report on the findings: United Press International, the New York Times Well blog, the Scientific American, and CBS News.

A paper released this week by Health & Society Scholars alumna Elizabeth Rigby, PhD, MA, looks at what can best predict a state’s resistance to the health reform law, the Washington Post Wonk blog reports. In states asked to make the most drastic changes under the law, and with greater public opposition—which was largely driven by the party affiliation of the state’s elected officials—resistance was higher, she concluded.

Renee Y. Hsia, MD, MSc, an RWJF Physician Faculty Scholar, is the lead author of a study that finds emergency department overcrowding and ambulance diversions are more likely to happen at hospitals in areas with large minority populations. “If you pass by a closer hospital that is on diversion for a hospital 15 minutes down the road, you are increasing the amount of time the patient is in a compromised situation,” Hsia told Health Canal. Read a post Hsia wrote for the RWJF Human Capital blog about her research.

Almost half of adults with type 2 diabetes report acute and chronic pain, according to a study led by RWJF/U.S. Department of Veterans Affairs Physician Faculty Scholar Rebecca Sudore, MD. Health Canal reports on the findings and the authors’ recommendations, which include making palliative care part of standard management of the disease.

This post is part of a series in which Robert Wood Johnson Foundation (RWJF) leaders, scholars, grantees and alumni offer perspectives on the U.S. Supreme Court rulings on the Affordable Care Act. Julia Lynch, PhD, is an associate professor at the University of Pennsylvania. Lynch is a recipient of a 2006 RWJF Investigator Award in Health Policy Research at the University of Pennsylvania and an alumna of the RWJF Scholars in Health Policy Research program (2003-2005).

The first emergency room is one you know: the ED in your nearest inner-city or rural hospital. There you’ll find trauma cases, heart failures, emergency appendectomies, heroic rescues by doctors and nurses working through the night, just like on TV. But also, waiting in chairs (lots of chairs), the frequent fliers, the preventable complications of asthma and diabetes, the people awaiting primary care in the worst possible medical environment for it. These are America’s emergency rooms.

And then there are Italian emergency rooms. As an expat living in Italy, I’ve navigated hundreds of miles of red tape to get a car registered, a telephone line installed, a tax ID number. I’ve paid notaries hundred upon hundreds of Euro for the stamps and forms needed to make the transactions of daily life (renting an apartment, selling a car) legal. Just imagine the emergency room. Better yet, don’t. I’ll tell you about it.

Some years ago, just after my husband and I had moved to Italy for my research, he cut his finger while preparing dinner. It looked bad, but it was Saturday night, and the one doctor we knew of who accepted our weird Belgian insurance policy for expats wasn’t in his office. So when the cut failed to stop bleeding overnight, we reluctantly made our way to the city hospital, asked for directions to the pronto soccorso (literally “immediate aid”), and prepared ourselves for a very long wait.

In the area to which the hospital greeter had directed us, we found a closed door, and three empty chairs in the hallway. After some confused wandering around, we knocked on the door, and once again asked for directions to the elusive ER waiting room. A doctor poked his head out, pointed to the three chairs, and said he’d be with us as soon as he finished patching up a motorcycle accident.

How long would that take, we wondered? And how many heart attacks, asthma attacks, and gunshot wounds would come in while we were waiting?

But the remaining chair in the hallway remained empty; and within ten minutes, the very same doctor who had answered our knock glued my husband’s finger back together and sent us on our way. Minimal wait, one doctor, no paperwork, and no charge—despite the fact that neither of us had an Italian National Health Service (NHS) card. Our Belgian insurance policy would not be billed. The doctor explained proudly that Italy’s NHS looked after everyone, even visitors.

And that’s not all: we didn’t know at the time that there is a designated doctor for every quartiere (neighborhood) in Italy, called the guardia medica, on call for minor nighttime emergencies. The doctors of the guardia medica, which I’ve also since had the occasion to call, are paid by the Italian state. They make house calls, with a little black bag and everything. The doctor for our quartiere could have glued my husband up on a Saturday night, in the comfort of our own home, again at no charge.

I know you must be thinking “But all this must be terribly expensive!” It’s true. Since our visit to the Italian ER, many patients of the NHS have been subjected to new out-of-pocket charges for medicines and specialist visits, and lines have grown longer in emergency departments as regional health budgets have come under pressure. But primary and emergency care is still free at the point of service. And Italy still spends considerably less than its neighbors do on health care: $2,870 per capita in 2008, compared to $3,129 in the UK, $3,696 in France, $4,063 in the Netherlands—and $7,538 in the U.S. Even so, income disparities in both access to care and health outcomes remain small in Italy, and most readers of this blog will know that Italy outperforms the U.S. on virtually every indicator of health and well-being.

Where does this tale of two emergency rooms leave us? The Affordable Care Act (ACA) brings us nowhere near a National Health Service on the Italian or British model. And not even the most ardent advocates of cost-effective medicine can imagine a way, under the ACA, to reduce our health care budget by 60 percent to bring us in line with what Italy spends on a per capita basis.

What the ACA does do is bring us one step closer to being able to say -- as that Italian ER doctor could -- that our health care system “looks after everyone.” It may even bring us nearer to the day when the waiting rooms of our emergency departments aren’t packed with patients seeking primary care, and care for complications resulting from a lack of primary care. Perhaps even a day when our emergency departments look a little more like three empty chairs in a hallway.