HCM 491 Module 3 Evidence Review Short Paper Example

What Works for Toothaches in the ED? An Evidence Review for the Marlow Capstone

[Student Name]

Southern New Hampshire University

HCM 491: Health Sciences Capstone

Module Three Short Paper

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

What Works for Toothaches in the ED? An Evidence Review for the Marlow Capstone

Module Two established that Marlow Regional Hospital's 1,452 dental visits a year are driven largely by a missing referral link, limited adult Medicaid coverage and ED treatment that relieves symptoms without fixing causes. Before proposing a solution, this paper asks what research shows about reducing such visits. It describes the search, reviews the evidence by theme, appraises each study's strength and fit and draws implications for the capstone proposal.

How the Search Was Done

PubMed, CINAHL and Google Scholar were searched for studies from 2010 onward using combinations of emergency department, dental, nontraumatic dental conditions, referral, navigation, Medicaid and opioid. Studies were kept if they measured ED dental visits, follow-up after an ED visit or ED dental prescribing. Opinion pieces and studies of children only were excluded. Nine studies met the criteria, and two more were added from reference lists after screening.

Theme 1: Coverage Changes Visits

The strongest evidence concerns insurance. Singhal et al. (2015) found that when California eliminated most adult Medicaid dental benefits, dental emergency visits and the money spent on them climbed. Elani et al. (2020) used a difference-in-differences design across 33 states and found that dental ED visits fell 14.1% in states that expanded Medicaid and covered adult dental care, while they rose in states without that combination. Giannouchos et al. (2023) confirmed the pattern: declines after expansion were concentrated in states whose Medicaid programs offered real dental benefits rather than emergency-only coverage.

What Theme 1 Means for Marlow

These are large quasi-experimental studies with consistent results, so the evidence is persuasive. But the lever is state policy, which a hospital cannot pull. Marlow's state covers emergency extractions only, the very situation in which Giannouchos and colleagues saw no decline. The lesson for the capstone is twofold: a hospital program should not expect to erase the problem while coverage stays limited, and the hospital's data could support advocacy for broader benefits.

Theme 2: Coordination and Navigation

Care coordination aims to connect ED patients to the right follow-up. Jiang et al. (2022) evaluated a patient navigator program in an urban ED and reported fewer return ED visits and better adherence to follow-up appointments among patients who worked with navigators. The program served general ED patients rather than dental patients specifically, so the fit is indirect, but its mechanism, a person who books the appointment before the patient leaves, matches the gap identified in Marlow's five-whys analysis.

Stakeholder Views on Coordination

Sun et al. (2015) combined Oregon claims data with interviews of 51 ED dental visitors and community stakeholders. Interviewees identified contributors at the health system, community, provider and patient levels and proposed solutions including Medicaid benefit expansion, care coordination, community water fluoridation and patient education. The study's qualitative strand adds credibility to coordination as a solution because it came from patients and local leaders, not only researchers.

Theme 3: How the ED Treats Dental Pain

Fox et al. (2013) reported that an ED prescribing guideline for dental pain reduced opioid prescriptions at their hospital. Marlow's 2023 guideline appears to have had a similar effect, cutting opioid prescribing from 49% to 31% of dental visits. Because it compared one hospital's prescribing before and after the change, its design is weak, but its result is plausible and has already been replicated locally. What neither Fox nor Marlow's guideline addressed is what happens after discharge, which is where repeat visits arise.

Theme 4: Multilevel Strategies

Sun et al. (2015) concluded that reducing ED dental visits requires interventions at several levels at once. Read together, the themes support that view. Coverage explains why visits happen, navigation addresses what happens after the ED and prescribing guidelines shape what happens during the visit. No single study tested a combined hospital program, but the evidence suggests that a hospital acting on the levels it controls, while supporting change at the policy level, has the best chance of success.

Appraisal Summary

Table 1 summarizes the key studies, their designs, findings and fit with Marlow. Policy evidence is strongest in design but weakest in local control; navigation evidence is weaker and indirect but addresses the exact gap Marlow can close.

Table 1. Key Evidence and Fit With Marlow

Note. Appraisal by the author.

Gaps in the Evidence

The review found no rigorous evaluation of a hospital-to-dental-clinic referral pathway for adults with ED dental visits, no study of guaranteed urgent appointment slots and little research on what happens to frequent dental visitors specifically. Cost studies focused on charges rather than hospital cost or savings. These gaps mean the capstone proposal must be built from adjacent evidence and should include a strong local evaluation.

Implications for the Proposal

Five implications follow. First, the core intervention should be a navigator who books a dental appointment before discharge, adapting Jiang and colleagues' model. Second, the partner clinic should reserve urgent slots so navigators have openings to book. Third, the ED should extend its prescribing guideline to cover pain control and a standard discharge packet naming the clinic. Fourth, frequent visitors should receive proactive outreach. Fifth, the hospital should share its data with the state hospital association to support broader Medicaid dental benefits.

Limitations of This Review

Only English-language work from the three databases was considered, and the coordinator alone decided which records to keep, which risks missing relevant studies or applying criteria inconsistently. Unpublished hospital program reports, which may describe exactly the kind of pathway proposed, were not searched systematically.

Conclusion

Research shows that coverage strongly shapes ED dental visits, that navigation can improve follow-up and reduce returns and that guidelines can change ED prescribing. No study tested the exact combination Marlow needs, but together they support a multilevel hospital program focused on the referral link. Milestone One will analyze the problem and propose that program in detail.

References

Elani, H. W., Kawachi, I., & Sommers, B. D. (2020). Changes in emergency department dental visits after Medicaid expansion. Health Services Research, 55(3), 367-374. https://doi.org/10.1111/1475-6773.13261

Fox, T. R., Li, J., Stevens, S., & Tippie, T. (2013). A performance improvement prescribing guideline reduces opioid prescriptions for emergency department dental pain patients. Annals of Emergency Medicine, 62(3), 237-240. https://doi.org/10.1016/j.annemergmed.2012.11.020

Giannouchos, T. V., Reynolds, J., Damiano, P., & Wright, B. (2023). Association of Medicaid expansion with dental emergency department visits overall and by states' Medicaid dental benefits provision. BMC Health Services Research, 23, Article 625. https://doi.org/10.1186/s12913-023-09488-3

Jiang, L. G., Zhang, Y., Greca, E., Bodnar, D., Gogia, K., Wang, Y., Peretz, P., & Steel, P. A. (2022). Emergency department patient navigator program demonstrates reduction in emergency department return visits and increase in follow-up appointment adherence. The American Journal of Emergency Medicine, 53, 173-179. https://doi.org/10.1016/j.ajem.2022.01.009

Singhal, A., Caplan, D. J., Jones, M. P., Momany, E. T., Kuthy, R. A., Buresh, C. T., Isman, R., & Damiano, P. C. (2015). Eliminating Medicaid adult dental coverage in California led to increased dental emergency visits and associated costs. Health Affairs, 34(5), 749-756. https://doi.org/10.1377/hlthaff.2014.1358

Sun, B. C., Chi, D. L., Schwarz, E., Milgrom, P., Yagapen, A., Malveau, S., Chen, Z., Chan, B., Danner, S., Owen, E., Morton, V., & Lowe, R. A. (2015). Emergency department visits for nontraumatic dental problems: A mixed-methods study. American Journal of Public Health, 105(5), 947-955. https://doi.org/10.2105/AJPH.2014.302398