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A recent study titled “Hospitalisation for the surgical removal of impacted teeth: Has Australia followed the international trends?” by George RP, Kruger E, Tennant M., appears in the Australasian Medical Journal (AMJ) vol. 4, issue 8, pp. 425-430, 2011.

The study looks at a period of six years between 1999 and 2005 in which patients had impacted teeth removed under general anesthesia in a hospital in Australia. The authors state that the vast majority of teeth that are impacted are wisdom teeth (third molars). A total of 37.6% of all oral health hospitalizations over the six years were for hospitalizations. Most of the patients were females with an average age of 21.6. The majority of patients were hospitalized at a private hospital and privately insured.

A total of 47,411 patients were hospitalized in Western Australia for the oral condition ‘Impacted/embedded teeth’ during the six-year study period. A total of 60.8% of the patients admitted were between age 15 and 24. A figure in the paper shows the full age distribution. A total of 86.6% of the patients were hospitalized at a metropolitan private hospital and a total of 74.9% of the patients were insured and were treated at a metropolitan hospital (92.1%).

The estimated costs for all of the patients were over $65 million over the 6 year period. The average cost was $A 1,388 with the average cost increasing a bit over the 6 year period. The average length of stay was 1 day.

In the discussion the authors state

“The highly privatised healthcare provision in oral health makes a contrast to the more managed approach in general health through the influences of Medicare and state and federal policy…Non-Indigenous people are far more likely to be hospitalised for removal of impacted teeth among all age groups.”

It is not clear from the study if the indigenous people do not receive as much treatment for impacted wisdom teeth due to differences in diet, prevelance, etc. or if it is due to generally being more economically disadvantaged with a lack of private dental coverage.

Near the end of the discussion some of the changes in removing healthy impacted wisdom teeth are discussed in the U.K. The authors state that many clinicians continue to remove non-pathological teeth.

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Previously in this post Oral Surgeon Investigated for Reusing Needles and Syringes it was discussed how last summer in 2012 an oral surgeon in Colorado was investigated for re-using syringes and needles while performing various oral and facial surgery procedures. Around 8,000 patients were told to be tested for potential HIV, hepatitis B, and hepatitis C.

Recently, in Oklahoma around 7,000 patients were told to be tested for potential HIV, hepatitis B, and hepatitis C who were treated by an oral surgeon due to his potentially rusty instruments and lax sterilization procedures.

A complaint by the Oklahoma  Board of  Dentistry was filed against the oral surgeon on March 26, 2013. It is located over at http://ftpcontent.worldnow.com/ktul/documents/Harrington_Complaint_OBD.pdf.

The complaint says that an unidentified patient who was treated by the oral surgeon tested positive for HIV and hepatitis C shortly after being treated for dental procedures. The complaint says that during the Dental Board’s investigation there were multiple sterilization issues, multiple cross contamination issues, the drug cabinet was often unlocked, and some of the dental assistants were routinely providing the IV sedation for some procedures. In addition, it was found that no written infection prevention policies and procedures were available or used.

The complaint goes on to say that the oral surgeon was a menace to the public health for practicing dentistry in an unsafe or unsanitary manner and committed gross negligence by deferring decisions and supervision of cleaning and infection control to dental assistants.

The American Dental Association (ADA) posted on March 29, 2013, that they are monitoring the news story of the Oklahoma oral surgeon, see ADA cites infection control resources as media focuses on Oklahoma oral surgeon. The ADA also issued a press release.

The ADA says

“The ADA has long recommended that all practicing dentists, dental team members and dental laboratories use standard precautions as described in the Centers for Disease Control and Prevention’s Infection Control in Dental Health Care Settings guidelines…Infection control procedures are designed to protect patients and health care workers by preventing the spread of diseases like hepatitis and HIV. Examples of infection control in the dental office include the use of masks, gloves, surface disinfectants and sterilizing reusable dental devices. In addition, dental health care providers are expected to follow procedures as required by the Occupational Safety and Health Administration.”

The ADA also recommends that if dental patients have any concerns they discuss with their dentist their infection control procedures. The ADA also issued several talking points to dentists to help them discuss infection control with their patients.

Additional Source: Donna Domino, “7,000 patients warned of possible hepatitis, HIV exposure,” DrBicuspid.com. March 29, 2013

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An interesting article appears in the Fall 2012 issue of the “The Journal of Law, Medicine & Ethics” titled “Justice and Fairness: A Critical Element in U.S. Health System Reform,” written by Paul T. Menzel.

In the article Paul discusses how unfettered competitive markets in health insurance generate market failure. The market failure of course is the fact that in an unfettered competitive market, health insurance will inevitably be out of reach for many (even most) of those who desire and need it most.

In the article Paul discusses a term he coins the Just Sharing principle

“The financial burdens of medical misfortunes ought to be shared equally by well and ill alike, unless individuals can be reasonably expected to control those misfortunes by their own choices.”

Paul goes on to say

“Just Sharing is incompatible with pre-existing condition exclusions, high degree of premium variation by subscriber risk, rescission of insurance when a subscriber becomes high-cost, and other market segmentation devices that inevitably arise in an unfettered competitive insurance market, creating market failure. If one only bars insurers from using these devices, however, then the “death spiral” for insurance begins: community-rated premiums lead even more of the likely well to forego insurance, which this raises premiums for remaining subscribers even more, and the cycle deepens. Basic insurance must be made mandatory for a competitive market to avoid leaving many of those who most need insurance high and dry. The heart of the moral objection to leaving many high and dry is that the likely well ought to contribute more to insurance than their individual risk situation alone warrants. That is, a good share of the expense of illness should be shared by well and ill alike.”

In the middle of the article Paul goes onto a discussion of what he coins the Equal Opportunity for Welfare along with the Emergency Medical Treatment and Active Labor Act. I won’t go into all these details here so I encourage you to read the article.

Later in the article Paul addresses the issue of comparative cost effectiveness.

“Suppose that for treating a given condition, two treatments are equally effective but not equally cost-effective; one carries higher cost for the same likely benefit. If I am required to contribute funding through mandated insurance, my assistance and investment is being partly wasted if it is devoted to care that is no more effective but costs more. If people are going to be required to share in the expenses of those who fall ill and need care, then plans and providers owe them a commitment not to waste their financial support. And covering less cost-effective treatments for a given condition, not just the more cost-effective measures for the same prospective patients, is — let’s be clear and accurate here — a waste.”

“This is exactly how various parties in European health care systems that provide care which is typically as effective as that in the U.S. but at little more than half the cost put the matter. The statement that “inefficiency is unethical” made by Marc Danzon, head of the WHO Regional Office for Europe, has become a kind of dictum in European circles. Efficiency is not a moral luxury. It is a moral obligation.”

The article by Paul certainly covers some interesting points and is worth the read.

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An interesting article by  Ronald Hamowy titled “Medical Responsibility” appears in the Fall 2012 issue of the The Journal of Law, Medicine & Ethics.

While I don’t agree with the all the points addressed in the article some of the points are worth mentioning.  Ronald says

“That we are part of some organic body and that we are interconnected so that we “belong” to and are responsible for each other is basically antithetical to our notion of the sovereignty of the individual. Nothing is more elemental to the nature of man than that he be in control over the decisions that affect him. And no decisions are more central to his existence than the medical care he receives. This extends to being able to determine the type and degree of medical care he opts for and to choose among those who might provide these services. Self-responsibility is not a burden — or at least not just a burden — but a method of insuring that the each of us has plenary control over our lives. And the only economic system compatible with individual autonomy is one of free markets, which also serves as the most efficient system for the production and distribution of goods and services.”

Now look I could go on and on about why I disagree with the notion that an individual is truly sovereign and that he has full control over the decisions that affect him. For example see the post Health Care Should Not Be Framed in the Personal Responsibility Narrative , Is What We Read Accurate or Sort of Accurate?, and Astroturfing And How Your Thoughts Are Being Manipulated by Corporate Interests. Our ability to form decisions and make choices is based on the information and beliefs that others provide us which shapes our own views and thoughts.

For example, before I was considering have my wisdom teeth extracted I conducted research on the internet to look at the potential risks and benefits. I also held certain beliefs about the world that were shaped by information I was receiving from others through the educational system, TV, friends, family, and etc. During this time I did not come across many of the risks of having wisdom teeth removed as indicated on my website http://www.teethremoval.com/complications.html nor was this information disclosed to me. I was not aware of the fact that many of the risks did not have to be legally disclosed every though I would have deemed them as material. Further, I was not aware of the controversy surrounding wisdom teeth extractions as discussed over at http://www.teethremoval.com/controversy.html.

Now it is no surprise to me where Ronald gets his opinions from since he is a Fellow in Social Thought at the Cato Institute in Washington, D.C.

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The Choosing Wisely Campaign is an initiative which I believe I first heard about in late 2010 launched by the ACR (American College of Radiation as the Imaging Wisely Campaign) The Imagely Wisely Campaign was designed to have people aware of the fact that certain medical imaging tests such as CT exams were sometimes over used and did not always have to be used in some instances. It seems that the Choosing Wisely Campaign was launched by the ABIM Foundation which is an organization designed to advance medical professionalism to improve patient care. In April 2012 the Choosing Wisely Campaign released some lists of tests and procedures commonly done in 9 medical professions that should be questioned.  In February 2013 an additional 18 lists of tests or procedures were released. The press release is located at http://www.choosingwisely.org/wp-content/uploads/2013/02/021513_CW-Phase-II-Press-Release-FINAL.pdf

On the website of the Choosing Wisely Campaign it states

“An initiative of the ABIM Foundation, Choosing Wisely is focused on encouraging physicians, patients and other health care stakeholders to think and talk about medical tests and procedures that may be unnecessary, and in some instances can cause harm.”

Consumer Reports is involved in helping to disseminate information to patients in a more readable format. On the about page of the campaign the following bullet points are presented.

• Supported by evidence
• Not duplicative of other tests or procedures already received
• Free from harm
• Truly necessary

The patient lists are located over at http://www.choosingwisely.org/doctor-patient-lists/ On this page are lists by the specialty societies currently participating which are supposed to be for doctors. There are also lists for for patients which consumer reports has helped to write along with the specialty societies. Both of these list are informative.

As an example of things provided in the list let’s take a look at the Colonscopy list for patients http://www.choosingwisely.org/doctor-patient-lists/colonoscopy/. The list states that having more than one colonscopy in a span of 5 to 10 years is not usually necessary. It also describes how colonscopy can in rare instances cause complications such as a tear in the colon and heavy bleeding. The list also provides some advice on how someone can protect themselves from colon cancer such as by changing their lifestyle and report any potential warning signs to a doctor.

As another example of things provided in the list let’s now take a look at the list for doctors from the American College of Radiology http://www.choosingwisely.org/doctor-patient-lists/american-college-of-radiology/. The list states that a CT should not be performed in a child with suspect appendicitis unless an ultrasound has been considered. The list also advocates against performing an x-ray in an ambulatory patient is not warranted unless something in the patient’s history or presentation suggests it.

I have previously discussed on this blog in the post How to Protect Yourself from Abusive Doctors how patients should work with their family medicine doctor to make sure tests and treatments advocated for by other doctors in other specialties is using the latest evidence. I have also addressed this in this post Tips to Prevent Medical Errors – AHRQ.

It is clear that is almost impossible for patients to accurately assess the need for and quality of care. Hence, I have also advocated for reviewing guidelines provide by the National Institute for Health and Clinical Excellence of the U.K.

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