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The direct and indirect costs of non-traumatic dental emergency room visits in British Columbia Ahmad, Syed Habeeb 2016

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The Direct and Indirect Costs of Non-Traumatic Dental Emergency Room Visits in British Columbia by Syed Habeeb Ahmad D.D.S., Baqai Medical University, 2012 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE in THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES (CRANIOFACIAL SCIENCES) THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver) September 2016 © Syed Habeeb Ahmad, 2016 ii Abstract  Objective: To assess the direct and indirect costs of non-traumatic dental visits at the Emergency Rooms (ERs) in British Columbia (BC). Methods: Services from the Canadian Institute for Health Information’s National Ambulatory Care Reporting System (NACRS) were acquired; NACRS contains data including diagnosis and procedures coded with the International Classification of Disease representing the conditions of oral cavity, salivary glands and jaws. Direct cost relates to the billing cost of non-traumatic dental patient seen at the ER as billed to the government. Direct costs from Ontario and Alberta were used to estimate the cost for BC. Indirect cost relates to loss of income in terms of time spent at the ER only.  Results: Between years 2012 and 2013, the number of visits for non-traumatic dental conditions at the ERs in Ontario, Alberta and British Columbia were 135,570 (1.16% of the total number of ER visits), 69,247 (1.51% of the total number of ER visits) and 22,786 (1% of the total number of ER visits), respectively. Out of 74, the 29 reporting emergency departments in 2013 in BC showed that the majority of the visits for non-traumatic dental conditions (70%) were made by adults between the ages 20 and 64 years-old; the most common complaints were dental and periapical abscesses and dental caries. The majority (70%) of non-traumatic dental patients in BC were non-urgent. On average the patients spent around 2 hours at the ERs at a cost ranging from $185.15 to $245.51 each to British Columbians, up to $2.99 million per year.  Conclusion: Although not all emergency departments in BC report data on non-traumatic dental visits, the cost to the tax payers is substantial. It was estimated to be between $185.15 and $245.51, whether using data from either Alberta or Ontario, respectively; the cost sums up to a total of $2.25 to $2.99 million per year for 29 of 74 reporting ERs. Therefore, use of emergency iii rooms for non-traumatic dental conditions not only adds an extra burden and contributes to overcrowding, but also makes the health care system costly.   iv Preface This study was approved by the University of British Columbia’s Office of Behavioral Research Ethics Board (Certificate Number: H14-03235) v Table of Contents  Abstract .......................................................................................................................................... ii Preface ........................................................................................................................................... iv Table of Contents ...........................................................................................................................v List of Tables ............................................................................................................................... vii List of Figures ............................................................................................................................. viii List of Abbreviations ................................................................................................................... ix Acknowledgements ...................................................................................................................... xi Dedication .................................................................................................................................... xii Chapter 1: Introduction ................................................................................................................1 1.1 Access to dental care in Canada...................................................................................... 1 1.2 The impact of oral diseases ............................................................................................. 4 1.3 Cost of dental care .......................................................................................................... 4 1.4 Use of emergency rooms for dental treatment ................................................................ 5 1.5 Research questions and objective ................................................................................... 8 Chapter 2: Material and Methods ................................................................................................9 2.1 Data set............................................................................................................................ 9 2.2 Data analysis ................................................................................................................. 13 Chapter 3: Results........................................................................................................................15 3.1 Demographic and characteristic features of emergency room visits ............................ 15 3.2 Main problem of non-traumatic dental emergency room visits and their codes ........... 18 3.3 Type of disposition of non-traumatic dental emergency room visits ........................... 19 vi 3.4 Time of non-traumatic dental emergency room visits .................................................. 21 3.5 Triage level of non-traumatic dental emergency room visits ....................................... 23 3.6 Mean length of stay ....................................................................................................... 24 3.7 Costs .............................................................................................................................. 28 Chapter 4: Discussion ..................................................................................................................32 Chapter 5: Conclusion and Limitations .....................................................................................38 5.1 Conclusion .................................................................................................................... 38 5.2 Limitations .................................................................................................................... 39 5.3 Implications................................................................................................................... 40 References .....................................................................................................................................43 Appendices ....................................................................................................................................56 Appendix A Emergency room presenting complaint list used in British Columbia................. 56 Appendix B Canadian emergency room diagnosis shortlist used in Alberta, Ontario and British Columbia ................................................................................................................................... 57  vii List of Tables  Table 1 - BC emergency rooms reporting to CIHI’s NACRS each fiscal year. ............................. 9 Table 2 - Comparison of data submission levels .......................................................................... 11 Table 3 - Data elements given by CIHI available on each level (level 1 and 3) in Alberta, Ontario and British Columbia .................................................................................................................... 12 Table 4 - Percentage of non-traumatic dental visits (NTDV) comparing with overall emergency room visits ..................................................................................................................................... 16 Table 5 - Demographic characteristics of non-traumatic dental patients ..................................... 17 Table 6 - International classification of diseases (ICD) codes used to diagnose main problem in Ontario, Alberta and British Columbia ......................................................................................... 18 Table 7 - Number of emergency room visit for non-traumatic dental conditions by groups and fiscal years in Ontario, Alberta and British Columbia .................................................................. 20 Table 8 - Number of non-traumatic dental visits by time of day (2012 -2013) ............................ 21 Table 9 - Odds of non-traumatic dental visits by age and gender in BC ...................................... 23 Table 10 - Mean length of stay by time of day in British Columbia ............................................ 25 Table 11 - Mean length of stay by time of day for groups A and B in BC ................................... 27 Table 12 - Direct cost for BC as estimated based on Ontario and Alberta ................................... 30 Table 13 - Indirect cost based on length of stay in British Columbia by fiscal year .................... 31 Table 14 - Total cost per non-traumatic dental emergency room visit in BC using Ontario and Alberta data, respectively, by fiscal year ...................................................................................... 31  viii List of Figures  Figure 1 - Percentage of non-traumatic dental visits by day of week in British Columbia .......... 22 Figure 2 - Triage level by provinces and fiscal years ................................................................... 24 Figure 3 - Length of stay in hours by different groups according to province and fiscal year ..... 26 Figure 4 - Length of stay in hours during day and night times in BC by different groups ........... 27 Figure 5 - Mean length of stay by season in BC by different groups ........................................... 28  ix List of Abbreviations  AB Alberta BC British Columbia CAD Canadian Armed Forces CCI Canadian Classification of Health Intervention CHMS Canadian Health Measure Survey CIHI Canadian Institute for Health Information ED Emergency Department ER Emergency Room IBM International Business Machine ICD International Statistical Classification of Diseases and Health Related Problems IFHP Interim Federal Health Program LICO Low Income Cut-Off  mLOS Mean Length of Stay MSP Medical Service Plan NACRS National Ambulatory Care Reporting System NIHB Non-Insured Health Benefits program NTDV Non-Traumatic Dental Visits ON Ontario OR Odds Ratio SD Standard Deviation SPSS Statistical Package for Social Science x VAC Veterans Affairs Canada xi Acknowledgements Most importantly, I have to acknowledge my parents and my wife Sarah Khan for their love and support. Thank you for giving me strength to reach for the stars and fulfill my dreams. My sisters deserve wholehearted thanks as well.  I would like to thank my thesis supervisor, Dr Mario A Brondani. The door to Dr Brondani’s office was always open whenever I needed to troubleshoot or had a question about my research or about my writing. He consistently allowed this research to be my own work, but steered me in the right the direction whenever I needed it.  I would also like to thank Dr. Garry Aslanyan and Dr Victoria Lee for their passionate participation and input. This research could not have been successfully completed without their suggestions.  I would also like to thank Dr. Batoul Shariati, as my committee member, and Dr. Soheilipour Shimae to whom I am gratefully indebted for their expert statistical advice and for their very valuable comments on this work. Finally, I must express my very profound gratitude to Muhammad Hasan Shahab and Humza Mughal for providing me with unfailing support and continued encouragement throughout my years of study and through the process of researching and writing this thesis. This accomplishment would not have been possible without you. Thank you. This thesis is only a beginning of my journey…! xii Dedication                                              I dedicate this thesis to my beloved father                                                             Syed Rasheed Ahmad                                                                         And                                                               To the loving mother                                                                   Wajida Khatoon                                 You have successfully made me the person I am becoming 1 Chapter 1: Introduction  1.1 Access to dental care in Canada In Canada, the administration and delivery of health care services is the responsibility of each province or territory in the form of fiscal transfers from the federal government under the Canada Health Act. Canada Health Act ensures that health care services are accessible to all insured individuals on the basis of need rather than on the ability to pay. (1) The Health Act describes the insured1 as a resident of a province (2) and functions on five principles, as follows: (1) 1. The provincial and territorial health plans must be administered and functioned on a nonprofit basis; 2. The provincial and territorial health plans must insure that all the medically necessary services are provided by health professionals within a hospital setting; 3. The provincial and territorial health plans must give equal rights to all insured persons to health coverage; 4. All insured persons must have reasonable access to medically services without financial and other barriers; 5. All insured persons must have health care coverage when they move within or outside Canada.2                                                  1 Canada Health Act defines a resident as "a person lawfully entitled to be or to remain in Canada who makes his home and is ordinarily present in the province, but does not include a tourist, a transient or a visitor to the province." (2) 2 There are some limits on coverage for services delivered outside Canada, and may need prior approval for non-emergency services provided outside their jurisdiction. 2 Although an important component of general health, oral care does not come under the umbrella of the Canada Health Act and remains mostly private for the majority of Canadians. (3) Some oral health care services might be covered by the federal government at the discretion of each province to specific groups of individuals through, for example, the Non-Insured Health Benefits program (NIHB), (4) the Veterans Affairs Canada, (5) the Interim Federal Health Program, (6) and the Canadian Armed Forces services. (7)   Aside from the federal government sponsored services, provincially financed dental programs offered by the government of British Columbia include: (8)  Healthy Kids Program, which assists children from low income families and provide $1,400 of basic oral care over the two calendar years. (9)  Welfare Assistance Dental Benefits, which aids to some adults with disabilities3. This program offers basic dental coverage of $1,000 over two calendar years. (12)  Dental Services for Low Income Families, which is available in 29 reduced fee dental clinics in British Columbia, offers reduced fee dental services delivered by dental students at their post-secondary institutions. (8)  With regard to offering publicly financed dental insurance, Canada is behind other developed countries, including Germany, the United Kingdom and Ireland that offer a robust dental coverage. (13) (14) Although the idea of having a national dental insurance plan is not new, the                                                  3 Disability refers to any degree of physical disability, infirmity, malformation or disfigurement that is caused by bodily injury, birth defect or illness. It can include those with diabetes mellitus, epilepsy, brain injury, and so on. (10). A disability must be both severe (e.g., mental or physical) and prolonged (e.g., long term or likely to result in death), and must prevent the individual from being able to work at any job on a regular basis. (11) 3 following reasons are believed to explain why dental insurance is not under Canada’s Health Care System: limited dental human resources, significant decrease in dental caries due to large scale services such as community water fluoridation, and a belief that maintaining oral health is individual’s own responsibility, not a social one. (14) Although some public funded dental services are available at both federal and provincial levels, most of them provide limited dental coverage to a small number of individuals.(15) The result is that the majority of Canadians (95%) pay for oral care services privately either out-of-pocket (44%) or by employment-based dental insurance (51%). (16) (17) (18)  Since lack of dental insurance and being of low socioeconomic status are the main restrictors to accessing oral care, (17) (19) disadvantaged and marginalized populations remain at a greater risk for oral diseases, mostly dental caries and periodontal disease (20) (21) (22) (23) Although the majority of these conditions are preventable in nature, their untreated consequences can lead to unnecessary pain, cause systemic complications and have a detrimental impact on quality of life especially for the working poor. It should be noted that one in every ten Canadians lives below the poverty line which is usually the case of minimal wage workers4. (24) The situation is even worse in BC where 1 in 7 British Columbians is believed to live below the poverty line, the second highest poverty rate after Nova Scotia. (25) Also, 1 in 5 children in British Columbia are from poor families. (25)                                                  4  Poverty can be defined either in absolute terms – inability to obtain the necessities of life, or in relative terms – being worse off than average. (21) The low income cut-off (LICO) represents the annual income at which a family may be in straitened circumstances because it barely covers the basic necessities compared to an average family of similar size. In 2015, the LICO referred to an annual income of $23,861 for 1 person, of  $29,706 for 2 persons, of $36,520 for 3 persons, and of $44,340 for 4 persons. (21) (22) 4 1.2 The impact of oral diseases The Canadian Dental Association refers to oral health as ‘an important part of overall health [as it] contributes positively to your physical, mental and social well-being and to the enjoyment of life's possibilities, by allowing you to speak, eat and socialize unhindered by pain, discomfort or embarrassment.’(26) (27) Despite the progress made to improve oral health all over the world, dental caries is still a major oral health concern to the extent that almost 90% of children and nearly 100% of adults are affected globally; it is a ‘silent epidemic’. (27) Similarly, 60% of Canadians aged 6 to 19 years-old have on average 2.5 decayed teeth, while 96% adults have a history of dental cavities. (28) (29) Children and their low income families, the working poor and those from middle-income groups are more vulnerable to oral diseases (20) (30) despite receiving some limited dental coverage  as per the government-sponsored programs described earlier.  Poor oral health has a profound effect on general health; several oral diseases are related to chronic conditions such as diabetes and cardiovascular complications. (26) (27) In fact, those affected by untreated dental caries and periodontal disease experience negative impacts on systemic and overall health especially during pregnancy, children’s growth and development, and at old age despite the poor understanding of how these impacts can actually take place. (30) (31) (28) Nonetheless, the presence of oral pain, limited mastication, difficulty in communicating and socializing greatly impacts people’s daily lives. (32)  1.3 Cost of dental care It is estimated that Canadians spend almost $14 billion annually on oral care, ranking second after cardiovascular diseases, but exceeding the direct cost of respiratory conditions, cognitive 5 illnesses, digestive diseases, and cancers. (16) (33) However, this cost comes mostly from private insurances and out-of-pocket expenses since only about 5% of that amount is publicly funded. (16) (34) (35) Moreover, this cost is an underestimation when the indirect cost associated with time lost from school, work and normal activities as well as loss in quality of life are considered. (33) (36) It is believed that annually almost 40% of Canadians lose five hours per school-day and seven hours per working-day due to dental-related problems. (37) In total, approximately 2.26 million school-days and 4.15 million working-days are lost each year in Canada due to dental-related office visits and dental sick days. (33) (37)    Given that regular dental visits are influenced mostly by ability to pay, (38) (39) it should come as no surprise that almost 17% of Canadians do not see a dental professional regularly while 16% avoid getting recommended dental treatment due to cost. (28) Nearly 1/3 of Canadians do not have any dental insurance. (28) The situation of low income families and those without dental insurance is even worse as they are 3 to 4 times more likely to not see a dentist when compared to higher income Canadians. (28) Without proper dental insurance and with limited financial means, those from the lower to middle socio economic bracket may rely on Emergency Rooms - ERs to seek for pain relieve while placing an extra burden on the already over-stretched Canadian health care system. (31) (38) (40)  1.4 Use of emergency rooms for dental treatment Patients with traumatic dental injuries involving complex damage to the dentoalveolar system and hard tissues with significant head, neck, or facial trauma may be evaluated and treated in a hospital emergency room setting. (41) (42) However, utilizing an ER to address non-traumatic 6 dental conditions such as toothache or dental abscesses is not only ineffective, but also inappropriate. (20)  But vulnerable and disadvantaged populations who can neither afford private dental insurance nor qualify for the public funded dental programs or have disposable income may end up in an ERs in order to try resolving or alleviating the complications of chronic oral diseases. (38) (20) (43) It was reported that 141,365 ERs visits for non-traumatic dental conditions were made between 2004 and 2006 in Ontario alone, far surpassing the number of visits due to diabetes and hypertension (38), two of the most prevalent chronic systemic diseases in Canada (44) (45). The estimates for BC are not fully known. Given the lack of affordability to oral and dental care, toothache and periapical abscess remain the main reasons for ER use at an estimated cost of $513 per visit on average to taxpayers. (40) (46) But inconsistency seems to exist in estimating or calculating such cost. For example, a report from the Canadian Institute for Health Information estimated that the cost per emergency room visit was $166 in Canada, (47) while in British Columbia the cost in emergency room can very between $260 to $510. (48)   From all the non-traumatic dental visits (NTDV) to the ERs in Canada, the majority (78%) are believed to be non-urgent in nature. (38) (49) The non-urgent visits may contribute to long waiting times other patients face at an ER which is currently more than four hours on average in Canada, the longest waiting time as within developed countries. (50) This may get even worse if the current flow of non-traumatic dental patients keep increasing with the growth of the population. A study from Ottawa has already reported a 52% increase of dental patients at the ERs from 2004 to 2014. (51) In the U.S., the average number of visits of non-traumatic dental patients to the ERs between 1997 and 2007 has doubled from what was initially predicted given the observed population growth for the same time-period. (52) The use of ERs for dental-related 7 pain relieve is a growing public health concern as most ERs do not have regular dentists on staff, nor are properly equipped to provide actual dental treatment. (53) The lack of dental professionals in the ERs adds stress to the medical team that is not sufficiently trained to properly diagnose dental diseases. (43) Without proper treatment to address the cause of a dental problem, drug prescription in the form of pain relieve and antibiotic therapy is frequently chosen. Overuse of analgesics contribute to the risk of therapeutic overdose and drug dependency while the over prescription of antibiotics adds to the problem of antimicrobial resistance. (54) (55)   Whether or not pain and antibiotic medication are given, many patients return to the ERs with either the same problem or a more serious, life-threatening consequence of the untreated dental condition. (56) (57) (58) For example, facial cellulitis is a common sequel of untreated dental abscesses, which can lead to dehydration, impaired central nervous system and airway obstruction. (57) Under such life threatening situation, hospital admission is required at a much higher cost, up to CAD $7,367 per admission.(59) Life threatening dental conditions continue to claim several lives both in United Stated and Canada. (60) (61) (62) (63) (64) Higher cost aside, admitted patients under this circumstance can spend five times longer in the hospital than non-admitted patients. Nearly 90% of the patients wait almost 21.4 hours in the ERs before admission, three times as long as those waiting for an operating room or critical care bed; it adds yet again unnecessary burden to the already overloaded health care system. (65) This is particularly relevant for vulnerable and disadvantaged populations who can neither afford private insurance nor qualify for the public funded dental insurance programs; they are more likely to visit the ERs for non-traumatic dental conditions. (68)  8 As ERs are constantly under pressure, non-urgent and non-traumatic dental visits contribute to overcrowding, mount up the cost of health care, and increase the wait time for patients with more severe health problems. (66) (67) But the overall cost of ERs visits can be much higher. Although there have been studies assessing the causes of dental ERs visits (38) (43) and their more direct financial implications, (34) there is a lack of understanding of the full burden of non-traumatic dental ER visits when the direct and indirect costs are considered, particularly in British Columbia.   1.5 Research questions and objective  The main focus of this study is on patients with non-traumatic dental condition visiting the emergency rooms in British Columbia. The research questions of this study are: 1. What is the direct cost of non-traumatic dental visits in ERs in BC? 2. What are the indirect costs of non-traumatic dental visits in ERs in BC? The above research questions will be addressed by the following objective: to calculate the direct and indirect costs of non-traumatic dental visits to ERs in British Columbia for the fiscal year April 1st 2012 to March 31st 2014.  9 Chapter 2: Material and Methods  2.1 Data set  Data from the Canadian Institute for Health Information (CIHI) National Ambulatory Care Reporting System (NACRS) was sought for the fiscal years of April 1st 2012 to March 31st 2014. This time-frame was chosen because the data from some of the 74 emergency departments in BC are available for this time period mostly (Table 1). (69) Given that BC data is limited as presented ahead, the same information from Ontario and Alberta was also sought to allow comparisons and cost-estimates.   Table 1 - BC emergency rooms reporting to CIHI’s NACRS each fiscal year. Fiscal Year Number of BC ERs Submitting to NACRS (74 in total) 2013-2014 29 2012-2013 20 2011-2012 6 2010-2011 0 2009-2010 2 2008-2009 3                        Source: Canadian Institute for Health Information  NACRS contains data for all hospital-based and community-based ambulatory care including day surgery, outpatient clinics and emergency rooms. The main focus of this study was on the available data that contained information on emergency room visits coded with the International Statistical Classification of Diseases and Health Related Problems (ICD-10- CA)5 K00 to K14                                                  5 The International Classification of Diseases and Related Health Problems, 10th Revision (ICD-10) is an international standard for reporting clinical diagnoses developed by the World Health Organization. 10 which represents diseases of oral cavity, salivary glands and jaws (full list can be found in Appendix B). (70) This information enabled the identification of: 1) the most frequent complain of non-traumatic dental patients visiting the ERs in BC, Alberta and Ontario, 2) the diagnosis given, and 3) the type of treatment given using the Canadian Classification of Health Intervention (CCI).6 (71) Aside from the information associated with ICD-10-CA, NACRS also contains data on age, gender, triage level (categorized into Level I to V consisting of resuscitation, emergent, urgent, less urgent and non-urgent cases, respectively)7, visit disposition and length of stay of non-traumatic dental patient seem at an ER (72); some of this information was utilized in this thesis. However, it is important to note that NACRS has different reporting levels: Level 1, Level 2 and Level 3 as per Table 2. Each level contains different content and amount of information, and vary between provinces. (73) For example, contrary to Alberta and Ontario, not all ERs in BC report to NACRS; in 2009 only 2 BC ERs reported while in 2012, 20 reported out of 74 (Table 1). As voluntary reporting only at Level 1 in BC, data are limited to some information including length of stay. It remains optional in BC to report on other level data such as ER discharge and ICD-10-CA for diagnosis treatment. In BC, the pick list (Appendix A) for presenting complaint and ER discharge diagnosis is used.                                                      ICD-10-CA is an enhanced version of ICD-10 developed by CIHI. It is also more adaptable than previous versions, allowing for the addition of codes as new diseases are discovered.  6 The Canadian Classification of Health Interventions (CCI) is the new national standard for classifying health care procedures. CCI is the comparable classification system to ICD-10-CA. 7 Resuscitation, emergent and urgent are grouped as urgent and less urgent and non-urgent cases as non urgent. 11 Table 2 - Comparison of data submission levels     As a result, data was collected targeting the following variables that fall under level 1 in BC and level 3 in Ontario and Alberta in order to answer the research questions and address the objective in this study (Table 3):  Level 1 contains data on age, gender, length of stay, triage level, visit disposition, total number of ERs visits, total number of dental/non-dental ER visits made by each patient in each fiscal year.  Level 3 includes all the variables from level 1, in addition to main problem, diagnosis given, type of treatment given and cost of each type of treatment/procedure.   As per tables 1 and 3, some of the BC data was not reported. In this case, the overall cost (see ahead) for the non-traumatic dental conditions at ERs in BC was estimated based on data from Alberta and Ontario as they submit the record at level 3 for the same condition/diagnosis. For example, information about the type of diagnosis (e.g., problem) and how each condition was treated was gathered from Alberta and Ontario. Since the diagnostic code is the same across the provinces (ICD-10-CA along with CCI), the treatment given to a particular dental condition in 12 Alberta and Ontario was used to estimate the information to BC under the same diagnostic code. In other words, it was assumed that a toothache or a dental abscess was treated similarly across different provinces.   Table 3 - Data elements given by CIHI available on each level (level 1 and 3) in Alberta, Ontario and British Columbia Data Requested Availability AB8 and ON9  (Level 3 Submissions) BC (Level 1 Submissions) Time spent on dental related emergency room visits (i.e. Length of Stay) Mandatory Data Element Age Mandatory Data Element (age and/or birth year) Gender Mandatory Data Element Main problem Mandatory Data Element (ICD-10 Codes) Not Available (level 1 optionally submits ‘Presenting Complaint’, from a pick list) Triage level: indicates the seriousness of the non-traumatic dental condition at the time of patient’s visit to the ER Mandatory Data Element Diagnosis given Mandatory Data Element (ICD-10 Codes) Not Available (level 1 optionally submits ‘ED Discharge Diagnosis’ from a pick list) Type of treatment given Procedure/ Intervention Codes are available, Mandatory Data Element (CCI Codes) Not Available                                                  8 AB - Alberta 9 ON - Ontario 13 Data Requested Availability AB8 and ON9  (Level 3 Submissions) BC (Level 1 Submissions) Cost of each type of procedure/treatment The cost of each individual procedure/treatment is not available. Average cost per visit can be made available Not Available Visit disposition (reflects the number of non-traumatic dental patients who are seen and discharged, hospitalized or transferred etc.) Mandatory Data Element Total number of dental visits at the ERs made by each patient in each fiscal year. Available   Color coding: Green refers to available information; Yellow refers to information that ‘may or may not be available’; Red refers to information that is not available.  Information including ethnicity, birth place, dental insurance, employment status, MSP billing and payment methods are not available in any of the Provinces’ data.         2.2 Data analysis All the variables of interest were transferred to Statistical Package for the Social Sciences (IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0) using Microsoft Excel spreadsheet. Continuous variables including age, time of ER visit, number of ER visits and time spent were summarized using descriptive statistics (n, mean ± SD). Categorical variables such as gender, main problem, diagnosis and triage level were summarized using frequencies and percentages to examine the sample characteristics and to identify the patterns of ER visits in the population. The following formula was used to estimate the total cost of non-traumatic dental visit to the ER based on the above variables: Total estimated cost = Direct Cost + Indirect Cost 14 Direct Cost: It relates to the cost of non-traumatic dental patient seen at the ER as billed to the government through the provincial health insurance plans.  Indirect Cost: It relates to the potential loss of income in terms of time spent at the ER, e.g., the monetary value attached to the time lost (from the length of stay10 in ER only) from work based on a BC minimal wage of $10.25/hour. The focus on the minimal wage is because the working poor or those at a minimal wage employment are more likely to use ERs for non-traumatic dental-related problems as they are may not have dental insurance and have unpaid work leave. (20) This indirect cost does not cover costs associated with transportation, meals, childcare and so on. Both direct and indirect costs were then added to estimate the overall cost of a non-traumatic dental visit to ERs in British Columbia.  Data are also presented by a number of different variables such as gender, age group, main problem, triage level, mean length of stay at the ER in order to identify the patient and visit characteristics for such types of services. Therefore, other associations and correlations were made given the richness of the data gathered.                                                   10 Length of stay is the duration in which a patient stays in the ER from the registration till s/he physically leaves the ER. 15 Chapter 3: Results  The results are presented in the following order:  Demographic and characteristic features of Emergency Room visits  Main problem of non-traumatic dental ER visits and their codes  Type of disposition of non-traumatic dental ER visits  Time of the non-traumatic dental ER visits  Triage level of non-traumatic dental emergency room visits  Mean length of stay  Costs  3.1 Demographic and characteristic features of emergency room visits Between fiscal years 2012 and 2013, the number of non-traumatic dental visits to the ER in Ontario, Alberta and British Columbia were reported to be around 1.16%, 1.5% and 1%, respectively (Table 4).  The non-traumatic dental patients were aged between 1 and 113 years-old across all three provinces. The number of NTDVs were almost evenly distributed between males and females; in 2013 in British Columbia the number of male visits were 6% higher as compared to female visits. Individuals between the ages of 6 and 12 years-old comprised the smallest portion of non-traumatic dental patients in the ER in all three provinces, about 4% of the total number of patients. 16 Table 4 - Percentage of non-traumatic dental visits (NTDV) comparing with overall emergency room visits PROVINCES 2012  2013  ONTARIO All ER visits NTDV 5,813,134 67,483 (1.16%)   All ER visits NTDV 5,857,622 68,087 (1.16%)  ALBERTA All ER visits NTDV 2,301,507 33,963 (1.47%)   All ER visits NTDV 2,321,894 35,284 (1.51%)  BRITISH COLUMBIA11 All ER visits NTDV  992,003 10,429 (1.05%)  All ER visits NTDV 1,248,403 12,357 (0.98%)    The majority of the ER visits for non-traumatic dental conditions consisted of adults; that is, patients between 20 and 64 years of age accounted for 70% for these visits and were five times more likely to visit the ERs as compared to those below the age of 19 years (Tables 5).                                                       11 In BC, out of 74 only 20 emergency rooms in 2012 and 29 in 2013 reported to CIHI.  17 Table 5 - Demographic characteristics of non-traumatic dental patients                                            ONTARIO                                                                        2012                                             2013                                                                    (N=67483)                                   (N=68087)  GENDER   Male Female          34782 (51.5 %)          32696 (48.5 %)            34917 (51.3%)           33168 (48.7%)  AGE 1 – 5            4012 (5.9 %)             3756 (5.5%) 6 – 12            2396 (3.6%)             2389 (3.5%) 13 – 19            4020 (6%)             3990 (5.9%) 20 – 34            23026 (34.1%)             23037 (33.8%) 35 – 64            27932 (41.1 %)             28676 (42.1%) 65 >            6096 (9%)             6237 (9.2%)                                                                                 ALBERTA                      2012                 (N=33963)                   2013               (N=35284) GENDER Male Female            17539 (51.6%)          16424 (48.4%)             18511 (52.5%)           16773 (47.5%)  AGE (YEARS)   1 – 5            3214 (9.5%)             3194 (9.1%) 6 – 12            1571 (4.6%)             1635 (4.6%) 13 – 19            1976 (5.8%)             2035 (5.8%) 20 – 34            11507 (33.9%)             12282 (34.8%) 35 – 64            13883 (40.9%)             14166 (40.1%) 65 >            1812 (5.3%)             1972 (5.6%)                                                                                  BRITISH COLUMBIA                      2012                  (N=10429)                    2013                (N=12357) GENDER Male Female             5880 (56.4%)           4547 (43.6%)              6909 (55.9%)            5443 (44.0%)  AGE   1 – 5             596 (5.7%)              750 (6.1%) 6 – 12             383 (3.7%)              423 (3.4%) 13 – 19             519 (5.0%)              660 (5.3%) 20 – 34             3686 (35.3%)              4436 (35.9%) 35 – 64             4455 (42.7%)              5108 (41.3%) 65 >             790 (7.6%)              980 (7.9%) 18 3.2 Main problem of non-traumatic dental emergency room visits and their codes The most common complaints related to the ER visit were dental/periapical abscesses, toothache and dental caries (Table 6).   Table 6 - International classification of diseases (ICD) codes used to diagnose main problem in Ontario, Alberta and British Columbia                                                                      Ontario ICD 10 CA codes Description Percentage 2012 2013  K047 Dental / Periapical abscess 33.4% 33.7%  K0887 Toothache 20.5% 20.2%  K029 Dental Caries 4.2% 4.1%  K112 Sialoadenitis 3.1% 3.4%  Z512 Chemotherapy 3.0% 3.5%                                                                       Alberta K047 Dental / Periapical abscess 36.6% 35.4%  K0887 Toothache 14.6% 14.9%  Z512 Chemotherapy 8.2% 9.8%  K029 Dental Caries 3.9% 3.8%  K120 Recurrent Oral Aphthae 2.8% 2.5%  K112 Sialoadenitis 2.7% 2.8%                                                               British Columbia12 K0887 Toothache 20.6% 18.1%  K047 Dental / Periapical abscess 18.3% 22.7%  K029 Dental Caries 6.8% 8.8%  K089 Teeth / Gums disorder 3.7% 5.4%                                                   12 36.2% in 2012 and 29% in 2013 data on main problem were missing.  19 Merely 10% of the NTDV were coded as having been X-rayed or given pharmacotherapeutic services (e.g. antibiotics, pain killers) (data not shown). However, there is no information available as to whether or not the other discharged patients did receive a prescription for similar pharmacotherapy.  3.3 Type of disposition of non-traumatic dental emergency room visits The data pertaining to non-traumatic ER dental visits are categorized into four main groups based on the type of disposition of patients were discharged from the ER as follows:   Group A indicates those patients who were seen at the ER, but left without receiving any treatment; it represents the majority of patients.   Group B includes those patients who got admitted to a hospital for any reason; the cost of admission is higher than the first group.  Group C comprises of those patients who either died on or after arrival at the ER. Group D contains patients who were either transferred to day surgery, to another ER or to a medical clinic.   As groups C and D comprise the lowest amount of patients, the vast majority of Non-Traumatic Dental Visits (NDTV) in all three provinces (98% in total) were comprised of patients who were seen and discharged on the spot as per Group A (Table 7).     20 Table 7 - Number of emergency room visit for non-traumatic dental conditions by groups and fiscal years in Ontario, Alberta and British Columbia  Groups Provinces Fiscal Year Number of NTDV       A (seen and    discharged) Ontario    Alberta   British Columbia  2012 2013  2012 2013  2012 2013  66,181 66,702  33,521 34,766  10,268 12,159        B (admitted) Ontario   Alberta   British Columbia  2012 2013  2012 2013  2012 2013  1,198 1,252  432 501  147 185        C (deaths) Ontario   Alberta   British Columbia  2012 2013  2012 2013  2012 2013  3 5  2 1  N/A N/A        D (others) Ontario   Alberta   British Columbia  2012 2013  2012 2013  2012 2013  101 128  8 16  14 13        21 Groups Provinces Fiscal Year Number of NTDV  Total (A+B+C+D) Ontario  Alberta  British Columbia  2012 2013 2012 2013 2012 2013 67483 68087 33963 35284 10429 12357  N/A refers to information not  given within the data set.           3.4 Time of non-traumatic dental emergency room visits  The non-traumatic dental visits were assessed based on time of day and day of week. NTDV that occurred between 9AM and 5PM were considered as daytime visits and the remaining time as nighttime visits. The seasons were divided roughly into summer (April through September) and winter (October through March.) In Ontario and Alberta, the proportion of the non-traumatic dental visits that occurred at nighttime was 9% and 11% higher, respectively, than those that occurred in daytime. In British Columbia, however, the nighttime visits were almost two-fold higher than the daytime visits, and slightly higher than the nighttime visits in Ontario and Alberta (Table 8).   Table 8 - Number of non-traumatic dental visits by time of day (2012 -2013) Provinces          Non-traumatic dental visits   Day Time    Night Time  Ontario 61723 (45.5%) 73803 (54.5%)  Alberta 30606 (44.2%)  38625 (55.8%)  British Columbia 8395 (36.9%)  14380 (63.1%)   22 When the data for NTDV was observed by day of the week, it was found that patients visited the ERs more on weekends (Figure 1) and at nighttime (Table 8) in BC.  Figure 1 - Percentage of non-traumatic dental visits by day of week in British Columbia   In 2013 the odds of females visiting ERs for non-traumatic dental conditions in daytime was 1.12 (95% CI:1.03-1.19) times higher than males in BC (P<0.05) (Table 9). The rate that the age group 1 to 19 years-old would visit the emergency room at nighttime was 1.4 times higher than those older than 65 years-old in BC. The probability that the age group 20 to 64 years-old would visit the emergency room for non-traumatic dental condition at night was 1.5 times higher than the age group 65 and older in BC (Table 9). 0.00%2.00%4.00%6.00%8.00%10.00%12.00%14.00%16.00%18.00%20.00%Sunday Monday Tuesaday Wednesday Thursday Friday Saturday23 Table 9 - Odds of non-traumatic dental visits by age and gender in BC OR= Odds ratio  3.5 Triage level of non-traumatic dental emergency room visits It should be noted that the 60-70% of patients with non-traumatic dental conditions were identified as non-urgent in all three provinces (Figure 2).                                            2012                                                                                    2013  Day Night P-value & OR Day Night P-value & OR Female 1705(37.5%) 2840(62.5%) OR = 1.07 (95% CI: 0.98-1.16) Not Significant  2088 (38.4%) 3353(61.6%) OR = 1.12 (95% CI:1.03-1.19) P<0.05 Male 2117 (36%) 3762 (64%) 2483 (36%) 4422 (64%)  1-19 yrs-old 538(60.8%) 960(68.4%) OR = 1.4 (95% CI: 1.2-1.7) P=0.0002 682(60.7%) 1148(68.1%) OR = 1.4 (95% CI: 1.2-1.6) P=0.0001 65 yrs and older 347(39.2%) 443(31.6%) 442(39.3%) 538(31.9%)  20-64 yrs-old 2938(89.4%) 5200(92.1%) OR= 1.4 (95% CI:1.2-1.6) P<0.0001 3449(88.6%) 6092(91.9%) OR= 1.5 (95% CI:1.3-1.7) P<0.0001 65 yrs and older 347(10.6%) 443(7.9%) 442(11.4%) 538(8.1%) 24    3.6 Mean length of stay  The mean length of stay (mLOS) relates to the average of time a patient spends at the emergency room, i.e., from the time of registration to the moment the patient leaves the emergency room. On average in BC, non-traumatic dental patients spent 2 hours at the ER during the daytime but less than 2 hours at nighttime (Table 10). Although in BC there were more non-traumatic dental visits at nighttime than daytime (Table 8), the mean length of stay (mLOS) at nighttime was significantly shorter than daytime (Table 10).  Figure 2 - Triage level by provinces and fiscal years 71.90%60.50%72.40%69.60%57.40%70.60%26.00%39.10%24%28.80%42.40%26.00%2% 0.40%4%1.60% 0.20%3.40%British Columbia Ontario Alberta British Columbia Ontario Alberta2012                                                                                 2013   Non-urgent Urgent Unknown25 Table 10 - Mean length of stay by time of day in British Columbia 2012-2013                  Mean Length of Stay Number of        visits Hours (±SD)   P-Value   Day Time   8377  2.11(2.34)   Night Time  14345  1.84(2.28)    P<0.01    Across the three provinces, patients who were admitted to the hospital waited at the emergency room between 9 to 13 hours—four to six times more than those who were seen and discharged from the ER without any further treatment (Figure 3). It is important to note that mean length of stay shown in figure 3 accounts only for the time taken to make a decision to admit a non-traumatic dental patient from an ER to a hospital only; it does not include the time they spent at the hospital onwards.          26       When a t-test was run for group A (with patients who were seen in the ER but discharged) and group B (with patients who were seen in the ER and admitted to the hospital) in two separate years, the mLOS at nighttime versus daytime was found to be statistically significant for both groups in British Columbia (Table 11).   15 10 5 0 5 10 15D(Others BC)B(Admitted BC)A(Seen and Discharged BC)D(Others AB)B(Admitted AB)A(Seen and Discharged AB)D(Other ON)B(Admitted ON)A(Seen and Discharged ON)2012 2013Figure 3 - Length of stay in hours by different groups according to province and fiscal year 27 Table 11 - Mean length of stay by time of day for groups A and B in BC                                       Group A                   Group B    Day Time mLOS(±SD)    Night Time mLOS(±SD) P-Value     Day Time mLOS(±SD)   Night Time mLOS(±SD) P-Value   2012 2013    1.93(1.4)      1.67(1.42) P<0.01   1.98(1.61)      1.77(1.62) P<0.01    10.04 (11.21)   7.44(7.12) P<0.027   10.04 (10.26)  13.02(14.32) P<0.028    It was also noted that in BC between 2012 and 2013, patient mean length of stay at nighttime for admission (Group B) increased by almost two-fold, however the daytime length of stay remained same (Table 11, Figure 4).  Figure 4 - Length of stay in hours during day and night times in BC by different groups  02468101214Day Time2012Night Time2012 Day Time2013 Night Time20131.931.671.981.7710.047.4410.0413.023.322.442.822.88HoursA (Seen and discharged)B (Admitted)D(Others)28 When compared by seasons (e.g., Summer – April to September; Winter – October to March), the mLOS for admitted patients was greater in winter than in summer and there was a constant increase in mLOS over the two fiscal years (Figure 5).    Figure 5 - Mean length of stay by season in BC by different groups    3.7 Costs As presented on page 27, the estimated total cost of a NTDV at an emergency room was calculated as Direct Cost (e.g., the cost in itself as given by the Canadian Institute for Health Information - this is likely the cost that researchers and administrators usually refer to when presenting similar data) + Indirect Cost (e.g., the potential loss of income given the length of stay at the ER). The rationale for using loss of income as an indirect cost was because the 02468101214Summer 2012Winter 2012Summer 2013Winter 20131.761.781.841.868.47 911.112.62.37 32.66 3HoursA(Seen and discharged)B(Admitted)D(others)29 working poor, or those at a minimal wage employment, would be more likely to use ERs for non-traumatic dental-related problems and are less likely to have dental insurance as known in the literature; the BC minimal wage used was $10.25/hour (as of 2015). Although other potential time losses likely incurred including travel time from work/home/school to the ER and back, transportation costs associated with this travel, meals and childcare, and the loss in quality of life and societal productivity, they were not considered in this analysis. Furthermore, in light of the restricted data available for British Columbia (Table 3), the cost of non-traumatic dental visits at the ERs in this province was calculated based on data from Ontario and Alberta as these two provinces report on Level 3 (Table 3). As such, the cost was estimated for the same condition; that is, it was assumed that a toothache or a dental abscess would be dealt with similarly regardless of the province. With this in mind, in 2013 the estimated cost (direct and indirect) of an ER visit for non-traumatic dental conditions in BC was about $185.15 when based on data from Ontario, and $245.51 when based on data from Alberta (Tables 12-14). The variation in cost is due to the different payment schedule in each province while assuming the same treatment/procedure given. For patients admitted to the hospitals from ERs, the cost doubled or quadrupled ($680.62 to $933.62, Table 14) since the average length of stay in 2013 was around 13 hours13 until an appropriate in-patient bed became available. This cost does not include the actual cost of the hospitalization per se, which is reported to be around $7,367 per admission.                                                    13 Length of stay for group B is the time patients waited in the ER until the decision was made or an appropriate bed became available for admission to the hospital. The amount shown for group B does not include the hospital/admission cost. 30 Table 12 - Direct cost for BC as estimated based on Ontario and Alberta Groups Provinces Fiscal Years Mean Direct Cost ±SD  A Ontario  Alberta   2012  2013  2012  2013   $ 157          58.23 $ 157          58.56 $ 211          74.41   $ 217          76.43     B Ontario    Alberta    2012 2013 2012 2013  $ 564          178.86 $ 560          170.19 $ 784          246.19   $ 813          236.21     C Ontario  Alberta  2012 2013 2012 2013  $ 261          85.11 $ 363          108.94 $ 340          196.46   $ 491           N/A14     D Ontario  Alberta  2012 2013 2012 2013  $ 170          99.91 $ 191          105.77 $ 204          27.61   $ 244          141.88                                                          14 Only one death occurred in Alberta in the year 2013 31 Table 13 - Indirect cost based on length of stay in British Columbia by fiscal year Groups Fiscal Years Mean Length of Stay (Hours) ±SD  Mean Indirect Cost ±SD  A 2012 2013  1.77 1.42 2.86 1.23  $18.13 14.57 $18.98 16.63      B 2012 2013  8.74 9.43 11.77 12.82  $89.53 96.75 $120.62 131.43      C 2012 2013  N/A N/A N/A N/A  N/A N/A N/A N/A      D 2012 2013  2.85 2.71 8.11 8.31  $29.17 27.78 $29.29 12.68   Table 14 - Total cost per non-traumatic dental emergency room visit in BC using Ontario and Alberta data, respectively, by fiscal year Groups Provinces Fiscal Years Total Cost     A Ontario  Alberta  2012 2013 2012 2013    $ 175.13   $ 175.98   $ 229.13   $ 235.98     B Ontario  Alberta  2012 2013 2012 2013  $ 653.53 $ 680.62   $ 873.53   $ 933.62     C Ontario  Alberta  2012 2013 2012 2013  N/A N/A N/A   N/A     D Ontario  Alberta  2012 2013 2012 2013  $ 199.17 $ 220.29 $ 233.17   $ 273.29 32 Chapter 4: Discussion  The results are discussed in light of the 2013 British Columbia data mostly because it is the most current and has the larger number of facilities reporting (#29) to the Canadian Institute for Health Information. The main objective of this study was to find out the cost of visits by patients with non-traumatic dental conditions to the emergency rooms in British Columbia, and it is discussed first while other important results are discussed thereafter. This thesis uses cost as a sum of the direct and indirect costs of the visits as follows: the direct cost relates to the amount billed to the provincial government when a patient was seen at the emergency room, which is usually the cost reported by government and researchers (74); the indirect cost is solely based on the time a non-traumatic dental patient spent at the emergency room. In turn, this indirect cost uses the time spent at the ER to calculate the potential loss of income, as highlighted in other studies, (75) (76) e.g., the monetary value attached to the time lost (from the length of stay in ER only) from work based on a BC minimal wage of $10.25/hour.   According to the data from 29 of 74 emergency rooms in 2013, nearly 12,357 British Columbians visited ERs for non-traumatic dental conditions, representing almost 1% of overall emergency room visits for that year, as a similar percentage reported elsewhere. (77) Out of these, 12,159 patients (98.5%) were seen and discharged. The main complaints were dental/periapical abscesses, toothaches, and dental caries (Table 6) which is consistent with reports from US and others from Canada. (78) (38) The combined direct and indirect costs of each visit to tax payers in British Columbia was estimated to be between $185.15 and $245.51, whether using data from either Ontario or Alberta as a benchmark, respectively. Although such 33 cost sums up to a total of $2.25 to $2.99 million per year, the cost per visit was lower compared to the cost reported by Maund (46) and Cummings, (48) $513 and $260-$510, respectively. Perhaps those studies also accounted for overhead expenses, administrative expenses, and physician compensation which were not part of estimation in this study. Nonetheless, a report from CIHI shows that the cost for each ER visit was $166 in British Columbia in 2009, (47) which is lower than what was found in this study probably because of inflation and/or the way cost was calculated. Nonetheless, inconsistencies in reporting a cost value abound.    Of interest, 98.5% of the non-traumatic ER dental visits (Table 4) were discharged without treatment to address the issue that lead to the visit in the first place: dental decay combined or not with toothache and abscess. In fact, Cohen and coworkers highlighted that when appropriate dental care is not provided, the costs and patterns of care delivered at the emergency rooms may be repeated and at a higher cost when the same patient returns seeking care for a now worsened unresolved condition. (58) The worsen conditions that now may require admission, which costs substantially more to the tax payers, contributes to possible overcrowding at emergency rooms, and impacts patients’ quality of life negatively from sleeping disturbance to inability to work, or even death. (36) In turn, the cost of providing care at the ER to a patient with a complicated oral condition that requires medical attention was found to vary between $680.62 to $933.62 (Table 14). However, if a decision is made to admit a patient to the hospital, the cost would jump to $7,367 per admission. (59) In the case of this study, approximately 1.5% (185 patients, Table 7) of all the non-traumatic emergency room visits in 2013 alone were admitted for the management of their conditions. This makes the total cost of admission of these patients to about $1.36 million, or $47,000 per each of the 29 reporting emergency rooms in BC. When 74 emergency 34 rooms are taken into consideration, the 1.5% of admissions would cost to British Columbians $3.47 million per year. Although the frequency of non-traumatic dental patients being admitted to hospitals is relatively low compared to all non-traumatic dental emergency room visits, its associated cost is much higher and the resulting hospitalization is among the most life-threatening consequences of failing to prevent or treat oral problems. (56) (57)   This study confirms Quinonez’s findings that men, more than women tend to use the ER for non-traumatic dental conditions. (38) In terms of age, patients aged between 20 and 64 years made five times more visits than those between the ages of 1 and 19 years, which may relate to the fact that most publicly funded dental programs target children and adolescents from low-income families rather than adults. (38) In fact, evidence from the U.S. and other jurisdictions validates the fact that the reduction in, or nonexistence of, publicly funded insurance coverage has been associated with increased visits to the ER for dental-related problems by low-income adults. (19) (38) (59) (79) In the majority of provinces in Canada, publicly financed insurance is offered almost entirely to children, individuals on social insurance, and disabled persons. Also, coverage is mostly basic in nature, restricted to dental emergencies. (15) Essentially, in the case of inadequate coverage, non-traumatic dental patients seeking dental care are required to spend more money out of pocket. Evidence has shown that the more a patient has to spend out of pocket, the less likely s/he may be to actually get care; the more likely they are to report negative oral health conditions. (15)  Also parallel to Quinonez results, this study found that most of the non-traumatic dental visits were non-urgent in nature. (59) There is evidence in the literature to support that emergency 35 rooms serve as a safety net for a substantial number of low income and uninsured dental patients in the hopes to seek regular care. (39) Other reasons that may add to the greater use of emergency rooms for oral health problems include increased dental decay potentially due to lack of fluoridation in community water supply systems, (77) and patients’ perception of free access to ER services at hospitals. (36) These non-urgent emergency room visits likely mirror the barriers in access to dental care by the working poor, (20) those who are not eligible to receive publicly financed insurance, and those who do not have employment-based dental insurance. (79) There is also evidence that middle-income groups in Canada are facing accessibility issues parallel to what has been seen in past years by the lowest income earners. (79)  The non-urgent emergency room visits also provide a window into the possible care-seeking patterns of individuals with limited access to dental care. Bedos and coworkers noted that the pathway of welfare recipients to dental care in Quebec involves medical settings given that difficulties in finding dentists who welcome low-income individuals without publicly funded insurance, and/or due to the nature of treatments needed which are not included in most public insurance plans (e.g., root canals). (68) Therefore, it can be assumed that non-traumatic dental patients would avail care in dental settings instead of emergency rooms if financial barriers to care were removed. However, it is imperative to note that removing financial barrier or providing public funded insurance does not guarantee access to dental care or utilization. (59)  Similar to other studies, the highest percentage of non-traumatic dental emergency room visits occurred on weekends (18%) and during the nighttime (63%) in British Columbia (38) (53). The higher number of non-traumatic dental ER visits during nighttime hours should not be entirely 36 surprising given that the majority of patients on minimal wage may face difficulty leaving their work place during normal working hours; British Columbia has the second highest poverty rate only second to Nova Scotia. (25) This rationale of working hours is also applicable to our findings for age from a statistical analysis where age was significantly associated with the time of non-traumatic dental emergency room visit. Compared to those 65 years and older, patients 20 to 64 years old were 1.5 times more likely to visit ERs during the nighttime, whereas older adults (65 and older) visited the ER more during daytime. This finding suggests that working poor adults with non-traumatic dental conditions might have waited until nighttime or worse, until the weekend, to try managing their dental problems while suffering. Likewise, those between 1-19 years old were 1.4 times more likely to visit the ER at nighttime compared to older adults. Other than nighttime being non-school time, there is much literature to support that a working parents/family member or guardian accompany pediatric patients during their dental visits to ensure that a valid medical history is taken and consent is obtained; these parents or family members work during the daytime. (80) This corroborates the findings of Thompson and colleagues showing that pediatric and adult ER visits for non-traumatic dental conditions do happen at nighttime and peak at times when people are less likely to be working or at school. (15) However, nighttime visits can also be done by patients with a dental emergency and who have a regular dentist, but given the regular dental offices working hours between 9AM and 5PM, have no other choice than an ER. Independently from the day and time that ER visits take place, ER physicians are not adequately trained to manage preventable oral conditions and most treatments typically are restricted to pharmacotherapeutic prescriptions. 37 In turns of mLOS, ER patients may stay long due to limited bed availability. A known factor that influences bed availability is the number of alternate level of care (ALC) patients15.  In this study, 185 (1.5%, group B) of all the non-traumatic dental patients in BC in 2013 stayed at the emergency rooms around 6 times longer than a non-admitted non-traumatic dental patient; these 185 admissions are an underestimation since only 29 emergency rooms out of 74 reported to CIHI in BC. Nonetheless, group “A” patients who were seen and discharged spent around 2 hours at the ER in British Columbia which contradicts the findings reported by CIHI of around 4.4 hours. (82) This study showed that in 2013 alone almost 24,318 hours were lost at 29 emergency rooms so that 12,159 non-traumatic dental patients could be seen, yet not properly treated. As a matter of fact, an average of 838.5 hours were lost at each of the 29 reporting ER in BC, or roughly a 1 year worth of working hours of an ER physician and supporting staff to provide care that was likely ineffective to address preventable dental conditions. This time could have been utilized to attend to other more serious life threatening conditions.                                                        15 ALC “provides a first look at patients in acute care hospitals across Canada who no longer need acute services, but are waiting to be discharged to a setting more appropriate to their needs” (81) 38 Chapter 5: Conclusion and Limitations  5.1 Conclusion  In British Columbia this study is the first of its kind to demonstrate the direct and indirect costs of non-traumatic dental emergency room visits. The vulnerable population that struggles with finances and disparities in oral health is most underserved. Marginalized populations with nowhere to go end up at the ERs, contributing to overcrowding, mounting up the cost of health care system and also suffering from a lower quality of life.  In 2013, about 1% of the British Columbians visiting ERs had done so with the main problem being dental/periapical abscesses and/or toothaches or dental caries. Each non-traumatic dental visit was completed in around 2 hours at a cost between $185.15 and $245.51 to the taxpayers. A small fraction of the patients (1.5%) stayed at the ER for 13 hours due to the severity of the oral condition which costed up $933.62 per patient. It is known that the majority of non-traumatic dental problems were considered to be non-urgent and that no definite interventions were received. Like others, this study has demonstrated that those aged 19 years and under and between 20 to 64 years were 1.4 times more likely to make an emergency room visit at nighttime as compared to those aged 65 years and older.   Besides the costs of accessing dental care by the underserved population the current study has demonstrated a potentially preventable number of emergency room visits and hospital admission, and related primary care for dental problems that are best treated in dental care settings. The cost 39 of each non-traumatic dental emergency room visits remain high and such visits are arguably preventable.   5.2 Limitations  This study also has limitations. One of the major limitations is that in 2012 and 2013 in BC 20 and 29 emergency rooms of 74 respectively reported data to the Canadian Institute for Health Information. Hence, the data from British Columbia lack important information including the total number of non-traumatic dental visits that occurred at the emergency rooms across the province in 2012 and 2013, the direct cost of each non-traumatic dental visit, and main intervention given. Additionally, since British Columbia does not submit data at level 3, data about the main problem, diagnosis, and cost of return visits were also missing.   There is also lack of sociodemographic data. Due to privacy and confidentiality guidelines set by CIHI, no patient-level information was released. Moreover, the financial and societal loss is probably much higher when the hourly job is related to essential services to society such as construction trade workers, primary industry and manufactory. In addition, the indirect cost did not include any other cost related to meals, child care, transportation and so on. As a result, the overall estimated cost was a gross underestimation. Non-traumatic dental patients who were seen in walk-in clinics were not included in the estimation either. Nonetheless, these details are important for overall costing and policy making.   40 Furthermore, the estimated cost has a large variation within Canada. For example, a report from Ontario shows an estimated cost of $513 per each ER visit; it is unknown what factors are considered to account for such estimate. Moreover, the results are not likely to be generalizable to Canada as health insurance plans vary across provinces16. It might not be generalizable to British Columbia either since only 29 out of 74 emergency rooms reported to CIHI in 2013. Finally, one cannot be certain how precisely the International Classification of Disease codes were used to refer to dental visits, diagnosis, and various dental procedures by health care professionals at the ERs.   5.3 Implications   The main objective of this research was to estimate the overall cost for dealing with preventable dental conditions in the ERs. The overall cost may better inform local health authorities, governing bodies and the Ministry of Health Province of British Columbia about the burden of oral diseases on the public healthcare system. It may also help to expand and improve the dental health care system for non-traumatic dental ER visits. Dental visits normally represent a small fraction of all emergency room visits, but they are associated with avoidable dental conditions and because of inappropriate treatment and inadequate follow-up, repeated ER visits add to the cost. Furthermore, costs for the services provided at an ER are more expensive than services delivered in a dental setting, putting financial pressure on the health care system. For example, assuming that on average each Canadian adult has three cavities on posterior teeth (83) involving                                                  16 For example, Alberta has only one health authority while BC has five independent health authorities. Ontario, on the other hand, has each hospital belonging to a local health network. (83) (84) (85) 41 at least one surface, the cost of a conservative dental procedure to treat each of these teeth would be around $105 per tooth involving one surface using amalgam filling (as per the British Columbia Dental Association 2014 fee guide). Given that in 2013 the total number of non-traumatic dental visits was 12,357 in BC, and assuming that each patient had at least one complaint at the ER visit of one tooth that was aching or with decay (as per table 6), the cost of providing dental treatment to these patients would be around $1.35 million. This amount is almost half of the amount that was actually spent to see these patients in the ER to whom no definitive treatment was provided. More importantly, this amount would translate to a dental problem actually being addressed properly.   In turn, careful assessment of the cost-effectiveness of alternative policies and approaches are needed to improve access to the oral health care system. For example, expansion of existing publicly funded dental plans may help those disadvantaged dental patients to maintain their oral health. Improved reimbursement rates may also increase dentists’ uptake of publicly funded dental patients. Access to oral care can also be improved by developing new and boosting existing professional task forces including dental therapists, like the Minnesota dental therapist program or the Alaska Dental Health Aide Therapists. Thus, policies that aim at expanding the public funds on dental care must include the assessments of costs to persons and to society, and must also be supported by equity considerations.   Lastly, this research provides distinctive information on an important public health concern, and evidence of direct and indirect costing where there had been none before. 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Available from: http://www.cpha.ca/en/about/offices.aspx               Canadian Emergency Department Information System (CEDIS)Presenting Complaint List (V3.0)Effective Date: April 2015Cardiovascular (001–050) # Environmental (201–250) # Genitourinary (301–350) (cont’d) #Cardiac arrest (non-traumatic) 001 Frostbite/cold injury 201 Polyuria 309Cardiac arrest (traumatic) 002 Noxious inhalation 202 Genital trauma 310Chest pain—cardiac features 003 Electrical injury 203 Mental Health (351–400) #Chest pain—non-cardiac features 004 Chemical exposure 204 Depression/suicidal/deliberate self-harm 351Palpitations/irregular heart beat 005 Hypothermia 205 Anxiety/situational crisis 352Hypertension 006 Near drowning 206 Hallucinations/delusions 353General weakness 007 Gastrointestinal (251–300) # Insomnia 354Syncope/pre-syncope 008 Abdominal pain 251 Violent/homicidal behaviour 355Edema, generalized 009 Anorexia 252 Social problem 356Leg swelling/edema 010 Constipation 253 Bizarre behaviour 358Cool pulseless limb 011 Diarrhea 254 Concern for patient’s welfare 359Unilateral reddened hot limb 012 Foreign body in rectum 255 Pediatric disruptive behaviour 360ENT—Ears (051–100) # Groin pain/mass 256 Neurologic (401–450) #Earache 051 Nausea and/or vomiting 257 Altered level of consciousness 401Foreign body, ear 052 Rectal/perineal pain 258 Confusion 402Loss of hearing 053 Vomiting blood 259 Vertigo 403Tinnitus 054 Blood per anus/melena 260 Headache 404Discharge, ear 055 Jaundice 261 Seizure 405Ear injury 056 Hiccoughs 262 Gait disturbance/ataxia 406ENT—Mouth, Throat, Neck (101–150) # Abdominal mass/distention 263 Head injury 407Dental/gum problem 101 Anal/rectal trauma 264 Tremor 408Facial trauma 102 Oral/esophageal foreign body 265 Extremity weakness/symptoms of CVA or TIA 409Sore throat 103 Feeding difficulties in newborn 266 Sensory loss/paresthesia 410Neck swelling/pain 104 Neonatal jaundice 267 Floppy child 411Neck trauma 105 Genitourinary (301–350) # OB/GYN (451–500) #Difficulty swallowing/dysphagia 106 Flank pain 301 Menstrual problems 451Facial pain (non-traumatic/non-dental) 107 Hematuria 302 Foreign body, vagina 452ENT—Nose (151–200) # Genital discharge/lesion 303 Vaginal discharge 453Epistaxis 151 Penile swelling 304 Sexual assault 454Nasal congestion/hay fever 152 Scrotal pain and/or swelling 305 Vaginal bleed 455Foreign body, nose 153 Urinary retention 306 Labial swelling 456URTI complaints 154 UTI complaints 307 Pregnancy issues, <20 weeks 457Nasal trauma 155 Oliguria 308 Pregnancy issues, >20 weeks 458CIHI - Canadian Institute for Health Information CEDIS - The Canadian Emergency Department Information System CommitteeICIS - Institut canadien d'information sur la santéSIGDUC - le comité des systèmes d'informations de gestiondes départements d'urgence canadiensBernard Unger1, Marc Afilalo1, Jean François Boivin2, Michael Bullard3, Eric Grafstein4, Michael Schull5, Eddy  Lang1, Antoinette Colacone1, Nathalie  Soucy1, Xiaoqing  Xue1, Eli Segal31 Emergency Multidisciplinary Research Unit, SMBD-Jewish General Hospital, McGill University, Montreal2 Centre for Clinical Epidemiology and Community Studies, SMBD-Jewish General Hospital, McGill University, Montreal 3 University of Alberta Hospital, University of Alberta, Edmonton, Alberta4 St. Paul's Hospital, Vancouver, University of British Columbia, Vancouver, British Columbia5 Sunnybrook Health Sciences Centre and Institute for Clinical Evaluative Sciences, University of Toronto, Toronto, Ontariowith/avecCanadian Institute for Health Information - Classifications & Terminologies and Clinical Administrative Databases (CAD) teamsInstitut canadien d'information sur la santé - les équipes de classifications & terminologies & des bases de données clinico-administratives (BDCA)Alberta Children's Hospital: Belanger F, Millar KBC Children's Hospital: Clarke M, Colbourne M, Haughton D, Hung G, Whitehouse SCanadian Pediatric SocietyCape Breton Regional Hospital: Currie TChildren's Hospital of Eastern Ontario: Farion KCH de l'Université de Montréal: Desaulniers P, Boulet M, Charbonneau L, Laurens JP, Jourdenais ECH de l'Université de Québec-Pavillon CHUL:Bernier D, Germain V, Guimont C, Nazair P, Turgeon RColchester Regional Hospital: Howlett MCredit Valley Hospital, Mississauga: Humniski AM, Letovsky E, Scampoli NCSSS Gatineau: Folot MH, Forest G,Michaud MN, Pham Dinh M, Sibille PFoothills Medical Centre, Calgary: Wertzler BGreater Niagara General Hospital: Turineck DGrey Nuns Comm. Hospital & Health Centre, Edmonton: Kruhlak RHamilton Health Sciences: Upadhye S, Rutledge GHealth Sciences Centre, Winnipeg: Sweetland RHôpital Maisonneuve Rosemont, Montreal: Mathieu BHôpital Sacré Coeur, Montreal: Chauny JMHospital for Sick Children, Toronto: Guttmann AHôtel Dieu de St-Jérôme: Gosselin MHôtel-Dieu de Lévis: Poitras JHotel-Dieu Grace Hospital, Windsor: Bradford PInstitut cardiologie de Montréal: Vadeboncoeur AIWK Health Centre, Halifax: Sinclair D, Taylor BKingston General Hospital: Blouin D, Dagnone G, Dungey P, Edwards KKitchener-Waterloo Health System: Kolleck DLake of the Woods District Hospital, Kenora: Moore SLakeridge Health Oshawa: Vandersluis RMarkham Stouffville Hospital: Austin DMount Sinai Hospital, Toronto: Ovens HMUHC-Montreal Children's Hospital and the Montreal General Hospital: Nemeth J, Troquet JMPrince George Regional Hospital: Rowe PQueen Elizabeth II Health Science Center, Halifax: Magee K, Campbell S, Maxwell D, Murray J, Watson MLRoyal Alexandra Hospital, Edmonton: Dong K, Dong S, Rabin EMUHC - Royal Victoria Hospital, Montreal: Beique MSMBD-Jewish General Hospital, Montreal: Dankoff J, Grad W, Stern E, Turner JSociety of Rural Physicians of CanadaSt. Michael's Hospital, Toronto: Cass D, Spence JSt. Paul's Hospital, Vancouver: Berringer RStanton Territorial Hospital, NWT: Hoechsmann AStollery Children's Hospital, Edmonton: Turner T, Dong KSt. John's Health Sciences Centre, NFLD: Morgan DThe Ottawa Hospital: Calder L, Nussbaum CThunder Bay Regional Hospital: Visser SToronto East General Hospital: Tyberg JUniversity of Alberta Hospital, Edmonton: Yao R, Dong SVancouver General Hospital: McKnight D, Moser MVictoria General & Royal Jubilee: Wheeler SWinnipeg Children's Hospital: Warda LplusMSSS: Ms. Sylvie Berger, Ms. Denise Trudel, Yves-Alain HemonCHU Ste Justine: Dr. Jocelyn GravelCED-DxS 2015Infectious and parasitic diseases D369 Benign tumor unspecified site F489 Neurotic disorder H669 OM - Otitis media Diseases of the respiratory systemA047 Clostridium difficile D489 Tumor of unknown behaviour F509 Eating disorder H709 Mastoiditis J019 Sinusitis, acuteA051 Botulism Hematologic and immunologic diseases F609 Personality disorder H729 Perforation tympanic membrane J029 Pharyngitis, acuteA059 Bacterial foodborne intox D570 Sickle-cell anemia crisis F99 Mental disorder, other H810 Ménière's disease J039 Tonsillitis, acuteA099 GE - Gastroenteritis / Diarrhea D649 Anemia Diseases of the nervous system H811 BPV - Benign paroxysmal vertigo J040 Laryngitis, acuteA1691 TB - Tuberculosis D65 DIC - Dissem intravasc coag G009 Meningitis, bacterial H813 Vertigo, peripheral other J041 Tracheitis, acuteA35 Tetanus D689 Coagulation defect G039 Meningitis, other H814 Vertigo of central origin J042 Laryngotracheitis, acuteA379 Pertussis / Whooping cough D6938 ITP - Idiop thrombocytopen purpura G049 Encephalomyelitis H919 Hearing loss J050 Croup - A obstruct laryngitisA38 Scarlet fever D696 Thrombocytopenia G060 Intracranial abscess H920 Otalgia J051 Epiglottitis, acuteA390 Meningitis, meningococcal D700 Neutropenia G061 Intraspinal abscess H931 Tinnitus J069 URTIA392 Meningococcemia, acute D759 Disease of heme organs G062 Extradural / Subdural abscess H939 Ear disorder, other J118 Influenza / Flu syndromeA419 Septicemia D899 Immune mechanism disorder G20 Parkinson's disease Diseases of the circulatory system J189 PneumoniaA46 Erysipelas Endocrine, nutritional and metabolic diseases G210 Malignant neuroleptic syndrome I099 Rheumatic heart disease J209 Bronchitis, acuteA480 Gas gangrene E039 Hypothyroidism G249 Dystonia I100 HT - Hypertension, benign J219 Bronchiolitis, acuteA481 Legionnaire's disease E059 Thyrotoxicosis G259 Extrapyramidal disorder I101 Hypertension, malignant J329 Sinusitis, chronicA483 TSS - Toxic shock syndrome E069 Thyroiditis G35 MS - Multiple sclerosis I200 UA - Unstable angina J36 Peritonsillar abscessA499 Bacteremia E100 DM type 1 coma G379 Demyelinating disease CNS I209 Angina pectoris J387 Laryngeal disorderA549 Gonorrhea E1010 DM type 1 DKA G4090 Epilepsy I219 AMI - Myocardial infarct, acute J390 Retro / Parapharyngeal abscessA630 Genital warts E1063 DM type 1 hypoglycemia G419 Status epilepticus I241 Dressler's syndrome J439 EmphysemaA64 Sexually transmitted infection E109 DM type 1 G439 Migraine I269 PE - Pulmonary embolism J440 COPD with respiratory infectionA692 Lyme disease E110 DM type 2 coma G448 HA - Headache syndrome I270 PPH - Primary pulm hypertension J441 COPD exacerbationA86 Encephalitis, viral E1163 DM type 2 hypoglycemia G454 TGA - Transient global amnesia I309 Pericarditis, acute J4590 AsthmaA879 Meningitis, viral E119 DM type 2 G459 TIA - Transient isch attack I313 Pericardial effusion J47 BronchiectasisB009 Herpes E149 DM unspecified G500 Trigeminal neuralgia I339 Endocarditis, acute J689 Toxic inhalationB019 Chickenpox / Varicella E162 Hypoglycemia (non-DM) G510 Bell's palsy I409 Myocarditis, acute J690 Aspiration pneumoniaB029 Shingles / Zoster E215 Parathyroid gland disorder G529 Cranial nerve disorder I429 Cardiomyopathy J80 ARDS - Acute  resp distr syndB059 Measles E222 SIADH G530 Postzoster neuralgia I441 AV block, 2nd J90 Pleural effusionB069 Rubella / German measles E232 Diabetes insipidus G560 Carpal tunnel syndrome I442 AV block, complete J939 PneumothoraxB083 5th disease E237 Pituitary gland disorder G610 GBS - Guillain-Barré syndrome I469 Cardiac arrest J949 Pleural conditionB084 Hand, foot and mouth disease E272 Addisonian crisis G629 Polyneuropathy I471 PSVT - Supraventr tachycardia J9508 Tracheostomy complicationB09 Exanthema, viral E289 Ovarian dysfunction G700 MG - Myasthenia gravis I472 VT - Ventricular tachycardia J9609 Respiratory failure, acuteB199 Hepatitis, viral E349 Endocrine disorder, other G729 Myopathy I4890 A Fib - Atrial fibrillation J9619 Respiratory failure, chronicB24 HIV E639 Nutritional deficiency G834 Cauda equina syndrome I4891 Atrial flutter J985 Mediastinal disorderB269 Mumps / Parotitis E835 Dis of calcium metabolism G839 Paralytic syndrome I495 SSS - Sick sinus syndrome J989 Respiratory disorderB279 Mononucleosis, infectious E849 Cystic fibrosis G919 Hydrocephalus I499 Cardiac arrhythmia Diseases of the digestive systemB349 Viral infection E860 Dehydration G934 Encephalopathy I500 CHF - Congestive heart failure K029 Dental cariesB379 Candidiasis E870 Hypernatremia G959 Spinal cord disease I609 SAH - Subarachnoid hemorrhage K047 Dental / Periapical abscessB49 Tinea / Fungal infection E871 Hyponatremia G9609 Cerebrospinal fluid leak I619 Intracerebral hemorrhage K0769 TMJ - Temporomandibr joint disB54 Malaria E875 Hyperkalemia G969 CNS disorder, other I620 Subdural hemorrhage nontrauma K0887 ToothacheB589 Toxoplasmosis E876 Hypokalemia Diseases of the eye and adnexa I64 CVA - Cerebrovascular accident K089 Teeth / Gums disorderB839 Pinworms / Helminthiasis E877 Fluid overload H029 Stye / Chalazion / Blepharitis I674 Hypertensive encephalopathy K119 Salivary gland disorderB852 Lice / Pediculosis E878 Dis electrolyte / Fluid dis H109 Conjunctivitis I679 Cerebrovascular disease K137 Oral mucosa disorderB86 Scabies E889 Metabolic disorder H113 Conjunctival hemorrhage I710 Dissection of aorta K149 Tongue disorderB89 Parasitic disease Mental and behavioural disorders H160 Corneal ulcer I719 Aortic aneurysm K20 EsophagitisNeoplasms F03 Dementia H169 Keratitis, unspecified I728 Aneurysm / Dissection, other artery K219 GERD - Gastroesoph reflux disC189 Neoplasm of colon F059 Delirium H189 Corneal disease I739 Peripheral vascular disease K222 Esophageal obstructionC259 Neoplasm of pancreas F072 Postconcussional syndrome H209 Iridocyclitis I749 Arterial embolism / Thrombosis K223 Perforation of esophagusC3499 Neoplasm of lung F100 Mental dis alcohol intoxicat H210 Hyphema I779 Arteritis K229 Esophageal disease, otherC449 Neoplasm of skin F103 Mental dis alcohol withdrawal H335 Retinal detachments I800 Superficial phlebitis legs K279 Peptic ulcerC5099 Neoplasm of breast F119 Mental dis due to opioids H359 Retinal disorder I809 DVT - Deep venous thrombosis K299 GastroduodenitisC579 Neoplasm gynecologic F139 Mental dis due to hypnotics H409 Glaucoma I839 Varicose veins of lower extrem K30 DyspepsiaC61 Neoplasm of prostate F149 Mental dis due to cocaine H431 Vitreous hemorrhage I850 Esophageal varices with bleed K319 Stomach / Duodenum disorderC6299 Neoplasm of testicle F159 Mental dis due stimulants oth H439 Vitreous body disorder I889 Lymphadenitis K358 Appendicitis, acuteC719 Neoplasm of brain unspecified F169 Mental dis due hallucinogens H449 Globe disorder, other I891 Lymphangitis K409 Hernia, inguinalC760 Neoplasm of head, face & neck F189 Mental dis due to solvents H46 Optic neuritis I959 Hypotension K429 Hernia, umbilicalC762 Neoplasm of abdomen F199 Mental dis due multip drug use H532 Diplopia I99 CVS disorder K469 Hernia, abdominal otherC763 Neoplasm of pelvis F209 Schizophrenia H539 Visual disturbance K509 Crohn's diseaseC767 Neoplasm, other F239 Psychotic disorder, acute H571 Ocular pain K519 Ulcerative colitisC900 Multiple myeloma F319 Bipolar affective disorder H579 Eye and adnexa disorder K529 Colitis, noninfectiveC959 Leukemia F329 Depression H609 OE - Otitis externa K559 Intestinal vascular disorderC969 Neoplasm hematologic, other F419 Anxiety disorder H612 Wax in ear K561 IntussusceptionCED-DxS 2015K562 Volvulus Diseases of the MSK system and connective tissueN12 Tubulo-interstitial nephritis Q430 Meckel's diverticulum R99 Other causes mortality T783 Angioneurotic edemaK566 SBO / LBO - Bowel obstruction M0099 Arthritis, septic N139 Obstructive uropathy Q431 Hirschsprung's disease Injury,poisoning and other T784 AllergyK567 Ileus M069 Arthritis, rheumatoid N179 ARF - Acute renal failure Q899 Congenital malformation T009 Sup inj multiple T790 Air embolismK578 Diverticulitis M089 Arthritis, juvenile N189 CRF - Chronic renal failure Q999 Chromosomal abnormality T0190 OW multip, uncompl T791 Fat embolismK579 Diverticulosis M1099 Gout N209 Urinary calculus Symptoms, signs and abnormal findings T0191 OW multip + FB / Infection T793 Post-trauma wound infectionK590 Constipation M1199 Arthropathy, crystal N23 RC - Renal colic R000 Tachycardia T0290 Fx multip, closed T794 Traumatic shockK599 IBS - Functional intestin dis M1399 Arthritis, unspecified N289 Renal and ureteral disease R001 Bradycardia T0291 Fx multip, open T814 Post-op / Procedure infectionK600 Anal fissure, acute M229 Patellar disorder N341 Nonspecific urethritis R002 Palpitations T110 Sup inj upper limb T850 Complication ventricular shuntK603 Anal fistula M239 Internal derangement of knee N390 UTI - Urinary tract infection R040 Epistaxis T111 OW upper limb T859 Complic prosth / implant / graftK612 Anorectal abscess M2509 Hemarthrosis N399 Urinary system disorder R042 Hemoptysis T130 Sup inj lower limb T869 Graft rejectionK613 Ischiorectal abscess M2549 Joint effusion N410 Prostatitis, acute R05 Cough T131 OW lower limb T887 Adverse effect of drugK623 Rectal prolapse M2559 Joint pain N433 Hydrocele R060 SOB - Dyspnea T147 Crushing inj unsp T889 Complic surg / med careK629 Anal / Rectal disorder M2599 Joint disorder N4408 Testicular torsion R061 Stridor T150 FB in corneaK631 Intestinal perforation M300 PAN - Polyarteritis nodosa N4592 Orchitis / Epididymitis R064 Hyperventilation T159 FB on external eyeK639 Intestinal disease, other M303 Kawasaki - Mucocut lymph nd synd N478 Phimosis / Paraphimosis R066 Hiccough T16 FB in earK649 Hemorrhoids M329 SLE - Systemic lupus erythematosus N483 Priapism R074 CP - Chest pain T171 FB in nostrilK650 Peritonitis, acute M349 Scleroderma - Systemic sclerosis N489 Penile disorder R092 Respiratory arrest T179 FB in respiratory tract Provisional CodesK709 Alcoholic liver disease M353 Polymyalgia rheumatica N509 Male genital organs disorder R100 Acute abdomen T181 FB in esophagus U0490 SARS suspectedK729 Hepatic failure M359 Connective tissue disease N63 Breast lump R102 Pelvic and perineal pain T185 FB in anus and rectum Contact with health servicesK739 Hepatitis, chronic M436 Torticollis N649 Breast disorder R104 Abdominal pain / Colic T189 FB in alimentary tract Z016 Radiological exam onlyK746 Cirrhosis (non-alcoholic) of liver M45 Ankylosing spondylitis N739 PID - Pelvic inflammatory dis R111 Nausea alone T190 FB in urethra Z017 Laboratory exam onlyK766 Portal hypertension M4649 Discitis N751 Bartholin's abscess R113 Nausea with vomiting T192 FB in vulva and vagina Z027 Issue of medical certificateK769 Liver disease M4799 Spondylosis N760 Vaginitis, acute R138 Dysphagia T290 Burns multip regions Z040 Blood-alcohol / drug testK8050 Choledocholithiasis M4809 Spinal stenosis N809 Endometriosis R17 Jaundice T301 Burn first degree Z044 Examination after alleged rapeK8080 Biliary colic / Cholelithiasis M4899 Spondylopathy N819 Female genital prolapse R18 Ascites T302 Burn second degree Z046 Legal psychiatric examK810 Cholecystitis, acute M509 Cervical disc disorder N832 Ovarian cysts R208 Paresthesias / Numbness T303 Burn third degree Z094 Cast check / Fracture follow upK8308 Cholangitis M542 Cervicalgia N8350 Torsion ovary R21 Rash T357 Frostbite Z099 Follow-up exam unspec TxK839 Biliary tract disorder M543 Sciatica N899 Noninflamm vaginal disorder R229 Swelling, mass and lump T390 Poisoning salicylates Z209 Contact communicable diseaseK859 Pancreatitis, acute M545 Back pain N926 Irregular menstruation R258 Abn involuntary movements T399 Poisoning acetaminophen Z299 Prophylactic measureK869 Pancreatic disorder M6269 Muscle strain N939 VB - Vaginal bleeding R2688 Gait and mobility abnormality T401 Poisoning heroin Z309 Contraceptive managementK909 Intestinal malabsorption M6299 Muscle disorder, other N946 Dysmenorrhea R300 Dysuria T405 Poisoning cocaine Z349 Pregnancy, normalK919 Postprocedural GI disorder M6599 Synovitis and tenosynovitis Pregnancy, childbirth and the puerperium R318 Hematuria T406 Poisoning narcotics Z37900 Delivery term multip births K922 Gastrointestinal hemorrhage M6659 Spontaneous rupture tendon O009 Ectopic pregnancy R33 Retention of urine T409 Poisoning hallucinogens Z37910 Delivery term single birthK929 Gastrointestinal disorder M702 Olecranon bursitis O021 Retained fetal products R36 Urethral discharge T424 Poisoning benzodiazepines Z38200 Newborn, single birth Dermatologic diseases M704 Prepatellar bursitis O034 Spontaneous abortion, incomplete R398 Urinary system Sx T439 Poisoning psychotropes Z38800 Newborn, multip birthL00 SSSS - Staph scalded skin synd M706 Trochanteric bursitis O039 Spontaneous abortion, complete R400 Altered LOC T469 Poisoning cardiotropes Z439 Stoma careL010 Impetigo M712 Baker's cyst O0899 Complic abortion / Ectopic / Molar R4029 Coma, unspecified T509 Poisoning other substances Z459 Adjustment implanted deviceL029 Abscess / Furuncle / Carbuncle M719 Bursitis, unspecified O15003 Eclampsia in pregnancy R410 Disorientation T510 Toxic effect ethanol Z488 Surgical aftercare evaluationL0300 Paronychia finger M722 Plantar fasciitis O20009 Threatened abortion R42 Dizziness T511 Toxic effect methanol Z5188 Medical care, otherL0301 Paronychia toe M7269 Necrotizing fasciitis O21909 Hyperemesis gravidarum R443 Hallucinations T518 Toxic effect other alcohols Z659 Social problemL039 Cellulitis M751 Rotator cuff syndrome O36999 Maternal care for fetal probl R458 Emotional symptoms / Suicidal ideation T529 Toxic effect solvent Z719 Counselling / Medical adviceL050 Pilonidal cyst with abscess M752 Bicipital tendinitis O47903 False labour R509 Fever T549 Toxic effect corrosive subs Z760 Issue of repeat prescriptionL139 Bullous disorder M754 Impingement synd shoulder O60101 Preterm delivery R51 HA - Headache T569 Toxic effect metal Z769 LWBS / AMA with no DxL211 Seborrheic infantile dermatitis M755 Bursitis of shoulder O75909 Complication of labour and delivery R53 Weakness / Fatigue T58 Toxic effect COL22 Diaper rash M759 Shoulder lesion O99809 Disease of peri-partum R55 Syncope / Vasovagal T599 Toxic effect gases / vapoursL259 Dermatitis, contact M765 Patellar tendonitis Conditions originating in the perinatal period R5609 Febrile convulsions T609 Toxic effect pesticideL299 Pruritus M766 Achilles tendonitis P229 Respir distress of newborn R5688 Seizures / Convulsions T629 Toxic effect noxious foodL309 Dermatitis / Eczema M779 Tendonitis, unspecified P369 Bacterial sepsis of newborn R570 Cardiogenic shock T639 Toxic effect venom animalL409 Psoriasis M7919 Myalgia P38 Omphalitis of newborn R571 Hypovolemic shock T659 Toxic effect substanceL42 Pityriasis rosea M7929 Neuralgia / Neuritis P599 Neonatal jaundice R579 Shock T66 Radiation effectsL509 Urticaria M7969 PLU - Pain in limb unsp P60 DIC of fetus and newborn R58 Hemorrhage T670 Heatstroke and sunstrokeL519 Erythema multiforme M819 Osteoporosis P619 Perinatal hematologic dis R599 Lymphadenopathy T679 Effect heat and lightL52 Erythema nodosum M8429 Fx delayed union P769 Intestinal obstruct newborn R600 Localized edema T68 HypothermiaL600 Ingrown nail M8699 Osteomyelitis P77 Necrotizing enterocol newborn R601 Generalized edema T703 Decompression sicknessL609 Nail disorder M889 Paget's disease of bone P789 Perinatal GI disorder R630 Anorexia T709 BarotraumaL739 Follicular disorder M8999 Bone disease, other P90 Convulsions of newborn R64 Cachexia / Failure to thrive T71 AsphyxiationL84 Corns and callosities M940 Costochondritis P929 Feeding problem of newborn R69 Diagnosis N/A in list  T749 Maltreatment syndrome / AbuseL899 Decubitus (pressure) ulcer M9499 Cartilage disease P95 Fetal death R799 Abn results blood chem T750 Effects lightningL989 Skin disorder Diseases of the genitourinary system P969 Perinatal disorders R938 Abn results imaging T751 Submersion injury (near drowning)N009 Nephritic syndrome, acute Congenital and chromosomal abnormalities R948 Abn results function studies T754 ElectrocutionN049 Nephrotic syndrome Q400 Pyloric stenosis, congenital R95 SIDS - Sudden infant death synd T782 Anaphylactic shock / ReactionN10 PyelonephritisCED-DxS 2015Head and face Thorax Shoulder and upper arm Wrist and hand Thigh and upper legS002 Sup inj periocular area S208 Sup inj thorax S4180 OW shoulder girdle, uncompl S600 Contusion finger(s), not nail S709 Sup inj hip / thighS009 Sup inj head S2190 OW thorax, uncompl S4181 OW shoulder girdle + FB / Infection S601 Contusion finger(s) + nail S7180 OW pelvic girdle, uncomplS0100 OW scalp, uncompl S2191 OW thorax + FB / Infection S42090 Fx clavicle, closed S609 Sup inj wrist / hand S7181 OW pelvic girdle + FB / InfectionS0101 OW scalp + FB / Infection S22090 Fx thoracic vert, closed S42091 Fx clavicle, open S6100 OW finger, not nail, uncompl S72190 Fx hip, closedS0110 OW eyelid, uncompl S22091 Fx thoracic vert, open S42190 Fx scapula, closed S6101 OW finger, not nail + FB / Infection S72191 Fx hip, openS0111 OW eyelid + FB / Infection S22200 Fx sternum, closed S42191 Fx scapula, open S6110 OW finger & nail uncompl S72900 Fx femur, closedS0130 OW ear, uncompl S22201 Fx sternum, open S42290 Fx upper end humerus, closed S6111 OW finger & nail + FB / Infection S72901 Fx femur, openS0131 OW ear + FB / Infection S22300 Fx rib, closed S42291 Fx upper end humerus, open S6190 OW wrist and hand, uncompl S73090 Disloc hipS0150 OW lip / mouth, uncompl S22301 Fx rib, open S42390 Fx shaft humerus, closed S6191 OW wrist and hand + FB / Infection S7319 Sprain / Strain hipS0151 OW lip / mouth + FB / Infection S22490 Fx ribs multip, closed S42391 Fx shaft humerus, open S62000 Fx scaphoid (hand), closed S789 Amputation legS0190 OW head, uncompl S22491 Fx ribs multip, open S42490 Fx lower end humerus, closed S62001 Fx scaphoid (hand), open Lower legS0191 OW head + FB / Infection S22500 Flail chest, closed S42491 Fx lower end humerus, open S62190 Fx other carpal, closed S8190 OW lower leg, uncomplS02100 Fx base skull, closed S22501 Flail chest, open S43090 Disloc shoulder joint S62191 Fx other carpal, open S8191 OW lower leg + FB / InfectionS02101 Fx base skull, open S231 Disloc thoracic vert S43100 Disloc acromioclavicular joint S62290 Fx first metacarp, closed S82000 Fx patella, closedS02200 Fx nasal, closed S259 Inj blood vessel thorax S43200 Disloc sternoclavicular joint S62291 Fx first metacarp, open S82001 Fx patella, openS02201 Fx nasal, open S26800 Contusion heart, no OW S435 Sprain / Strain AC joint S62490 Fx multiple other metacarpals, closed S82400 Fx fibula alone, closedS02300 Fx orbital floor, closed S26801 Contusion heart + OW S4379 Sprain / Strain shoulder S62491 Fx multiple other metacarpals, open S82401 Fx fibula alone, openS02301 Fx orbital floor, open S27200 Hemopneumothorax, tr no OW S489 Amputation arm S62590 Fx thumb, closed S82890 Fx ankle, closedS025 Fx tooth S27201 Hemopneumothorax, tr + OW Forearm S62591 Fx thumb, open S82891 Fx ankle, openS02600 Fx mandible, closed S27300 Contusion lung, no OW S5190 OW forearm, uncomplicated S62690 Fx other finger, closed S82900 Fx lower leg, closedS02601 Fx mandible, open S27301 Contusion lung + OW S52000 Fx olecranon, closed S62691 Fx other finger, open S82901 Fx lower leg, openS02900 Fx skull / facial, closed S27390 Inj lung, no OW S52001 Fx olecranon, open S63090 Disloc wrist S83000 Disloc patellaS02901 Fx skull / facial, open S27391 Inj lung + OW S52100 Fx head radius, closed S63190 Disloc finger S83190 Disloc kneeS030 Dislocation of jaw S27900 Inj intrathoracic organ, no OW S52101 Fx head radius, open S6359 Sprain / Strain wrist S836 Sprain / Strain kneeS0498 Inj cranial nerve S27901 Inj intrathoracic organ + OW S52500 Fx Colles', closed S6369 Sprain / Strain finger S859 Inj blood vessel lower legS050 Corneal abrasion / Inj conjunct S280 Crushed chest S52501 Fx Colles', open S6379 Sprain / Strain hand S8608 Inj Achilles tendonS059 Injury eye / orbit S52900 Fx forearm, closed S6498 Inj nerve wrist / hand S8698 Inj muscle / tendon low legS060 MHI - Concussion Abdominal, pelvis & back S52901 Fx forearm, open S659 Inj blood vessel wrist / hand S878 Crushing inj legS0625 Diffuse brain inj, no OW S3080 Sup inj low back / pelvis S530 Disloc radial head S6698 Inj muscle / tendon hand / wrist S889 Amputation lower legS0626 Diffuse brain inj + OW S3081 Sup inj abdominal wall S53190 Disloc elbow S678 Crushing inj wrist / handS0635 Focal brain inj, no OW S3085 Sup inj genitals S5348 Radial head subluxation (nursemaid's) S681 Amputation finger Foot and ankleS0636 Focal brain inj + OW S31000 OW lower back / pelvis, uncompl S5349 Sprain / Strain elbow S689 Amputation wrist / hand S901 Contusion toe(s), not nailS064 Epidural hemorrhage S31001 OW lower back / pelvis + FB / Infection S579 Crushing inj arm S902 Contusion toe(s) + nailS065 SDH - Traumatic subdural hemorrhage S31190 OW abdominal wall, uncompl S589 Amputation forearm S902 Contusion toe(s) + nailS066 SAH, traumatic S31191 OW abdominal wall + FB / Infection S909 Sup inj ankle / footS081 Amputation ear S31500 OW ext genital organs, uncompl S9130 OW foot, uncomplS092 Rupture ear drum, traumatic S31501 OW ext genital organs + FB / Infection S9131 OW foot + FB / InfectionS32090 Fx lumbar vert, closed S92000 Fx calcaneus, closedS32091 Fx lumbar vert, open S92001 Fx calcaneus, openS32100 Fx sacrum, closed S92100 Fx talus, closedNeck S32101 Fx sacrum, open S92101 Fx talus, openS109 Sup inj neck S32200 Fx coccyx, closed S92290 Fx other tarsal, closedS1190 OW neck, uncompl S32201 Fx coccyx, open S92291 Fx other tarsal, openS1191 OW neck + FB / Infection S32400 Fx acetabulum, closed S92300 Fx metatarsal(s), closedS12900 Fx cervical vert, closed S32401 Fx acetabulum, open S92301 Fx metatarsal(s), openS12901 Fx cervical vert, open S32800 Fx pelvis, closed S92400 Fx great toe, closedS131 Disloc cervical vert S32801 Fx pelvis, open S92401 Fx great toe, openS136 Sprain / Strain cervical spine and neck S331 Disloc lumbar vert S92500 Fx other toe, closedS159 Inj blood vessel at neck S3419 Lesion lumbar spinal cord S92501 Fx other toe, openS3438 Inj cauda equina S92900 Fx foot, closedS359 Inj vascular abd / pelvis S92901 Fx foot, openS36990 Inj intra-abd organ, no OW S93000 Disloc ankle jointS36991 Inj intra-abd organ + OW S93110 Disloc toeS37090 Inj kidney, no OW S93310 Disloc parts footS37091 Inj kidney + OW S9349 Sprain / Strain ankleS37990 Inj pelvic organ, no OW S936 Sprain / Strain footS37991 Inj pelvic organ + OW S978 Crushing inj ankle / footS382 Amputation penis / testicle S981 Amputation toeS3908 Inj muscle / tendon / abd / back / pelvis S984 Amputation footCED-DxS 2015Infectious and parasitic diseases D369 Benign tumor unspecified site F489 Neurotic disorder H669 OM - Otitis media Diseases of the respiratory systemA047 Clostridium difficile D489 Tumor of unknown behaviour F509 Eating disorder H709 Mastoiditis J019 Sinusitis, acuteA051 Botulism Hematologic and immunologic diseases F609 Personality disorder H729 Perforation tympanic membrane J029 Pharyngitis, acuteA059 Bacterial foodborne intox D570 Sickle-cell anemia crisis F99 Mental disorder, other H810 Ménière's disease J039 Tonsillitis, acuteA099 GE - Gastroenteritis / Diarrhea D649 Anemia Diseases of the nervous system H811 BPV - Benign paroxysmal vertigo J040 Laryngitis, acuteA1691 TB - Tuberculosis D65 DIC - Dissem intravasc coag G009 Meningitis, bacterial H813 Vertigo, peripheral other J041 Tracheitis, acuteA35 Tetanus D689 Coagulation defect G039 Meningitis, other H814 Vertigo of central origin J042 Laryngotracheitis, acuteA379 Pertussis / Whooping cough D6938 ITP - Idiop thrombocytopen purpura G049 Encephalomyelitis H919 Hearing loss J050 Croup - A obstruct laryngitisA38 Scarlet fever D696 Thrombocytopenia G060 Intracranial abscess H920 Otalgia J051 Epiglottitis, acuteA390 Meningitis, meningococcal D700 Neutropenia G061 Intraspinal abscess H931 Tinnitus J069 URTIA392 Meningococcemia, acute D759 Disease of heme organs G062 Extradural / Subdural abscess H939 Ear disorder, other J118 Influenza / Flu syndromeA419 Septicemia D899 Immune mechanism disorder G20 Parkinson's disease Diseases of the circulatory system J189 PneumoniaA46 Erysipelas Endocrine, nutritional and metabolic diseases G210 Malignant neuroleptic syndrome I099 Rheumatic heart disease J209 Bronchitis, acuteA480 Gas gangrene E039 Hypothyroidism G249 Dystonia I100 HT - Hypertension, benign J219 Bronchiolitis, acuteA481 Legionnaire's disease E059 Thyrotoxicosis G259 Extrapyramidal disorder I101 Hypertension, malignant J329 Sinusitis, chronicA483 TSS - Toxic shock syndrome E069 Thyroiditis G35 MS - Multiple sclerosis I200 UA - Unstable angina J36 Peritonsillar abscessA499 Bacteremia E100 DM type 1 coma G379 Demyelinating disease CNS I209 Angina pectoris J387 Laryngeal disorderA549 Gonorrhea E1010 DM type 1 DKA G4090 Epilepsy I219 AMI - Myocardial infarct, acute J390 Retro / Parapharyngeal abscessA630 Genital warts E1063 DM type 1 hypoglycemia G419 Status epilepticus I241 Dressler's syndrome J439 EmphysemaA64 Sexually transmitted infection E109 DM type 1 G439 Migraine I269 PE - Pulmonary embolism J440 COPD with respiratory infectionA692 Lyme disease E110 DM type 2 coma G448 HA - Headache syndrome I270 PPH - Primary pulm hypertension J441 COPD exacerbationA86 Encephalitis, viral E1163 DM type 2 hypoglycemia G454 TGA - Transient global amnesia I309 Pericarditis, acute J4590 AsthmaA879 Meningitis, viral E119 DM type 2 G459 TIA - Transient isch attack I313 Pericardial effusion J47 BronchiectasisB009 Herpes E149 DM unspecified G500 Trigeminal neuralgia I339 Endocarditis, acute J689 Toxic inhalationB019 Chickenpox / Varicella E162 Hypoglycemia (non-DM) G510 Bell's palsy I409 Myocarditis, acute J690 Aspiration pneumoniaB029 Shingles / Zoster E215 Parathyroid gland disorder G529 Cranial nerve disorder I429 Cardiomyopathy J80 ARDS - Acute  resp distr syndB059 Measles E222 SIADH G530 Postzoster neuralgia I441 AV block, 2nd J90 Pleural effusionB069 Rubella / German measles E232 Diabetes insipidus G560 Carpal tunnel syndrome I442 AV block, complete J939 PneumothoraxB083 5th disease E237 Pituitary gland disorder G610 GBS - Guillain-Barré syndrome I469 Cardiac arrest J949 Pleural conditionB084 Hand, foot and mouth disease E272 Addisonian crisis G629 Polyneuropathy I471 PSVT - Supraventr tachycardia J9508 Tracheostomy complicationB09 Exanthema, viral E289 Ovarian dysfunction G700 MG - Myasthenia gravis I472 VT - Ventricular tachycardia J9609 Respiratory failure, acuteB199 Hepatitis, viral E349 Endocrine disorder, other G729 Myopathy I4890 A Fib - Atrial fibrillation J9619 Respiratory failure, chronicB24 HIV E639 Nutritional deficiency G834 Cauda equina syndrome I4891 Atrial flutter J985 Mediastinal disorderB269 Mumps / Parotitis E835 Dis of calcium metabolism G839 Paralytic syndrome I495 SSS - Sick sinus syndrome J989 Respiratory disorderB279 Mononucleosis, infectious E849 Cystic fibrosis G919 Hydrocephalus I499 Cardiac arrhythmia Diseases of the digestive systemB349 Viral infection E860 Dehydration G934 Encephalopathy I500 CHF - Congestive heart failure K029 Dental cariesB379 Candidiasis E870 Hypernatremia G959 Spinal cord disease I609 SAH - Subarachnoid hemorrhage K047 Dental / Periapical abscessB49 Tinea / Fungal infection E871 Hyponatremia G9609 Cerebrospinal fluid leak I619 Intracerebral hemorrhage K0769 TMJ - Temporomandibr joint disB54 Malaria E875 Hyperkalemia G969 CNS disorder, other I620 Subdural hemorrhage nontrauma K0887 ToothacheB589 Toxoplasmosis E876 Hypokalemia Diseases of the eye and adnexa I64 CVA - Cerebrovascular accident K089 Teeth / Gums disorderB839 Pinworms / Helminthiasis E877 Fluid overload H029 Stye / Chalazion / Blepharitis I674 Hypertensive encephalopathy K119 Salivary gland disorderB852 Lice / Pediculosis E878 Dis electrolyte / Fluid dis H109 Conjunctivitis I679 Cerebrovascular disease K137 Oral mucosa disorderB86 Scabies E889 Metabolic disorder H113 Conjunctival hemorrhage I710 Dissection of aorta K149 Tongue disorderB89 Parasitic disease Mental and behavioural disorders H160 Corneal ulcer I719 Aortic aneurysm K20 EsophagitisNeoplasms F03 Dementia H169 Keratitis, unspecified I728 Aneurysm / Dissection, other artery K219 GERD - Gastroesoph reflux disC189 Neoplasm of colon F059 Delirium H189 Corneal disease I739 Peripheral vascular disease K222 Esophageal obstructionC259 Neoplasm of pancreas F072 Postconcussional syndrome H209 Iridocyclitis I749 Arterial embolism / Thrombosis K223 Perforation of esophagusC3499 Neoplasm of lung F100 Mental dis alcohol intoxicat H210 Hyphema I779 Arteritis K229 Esophageal disease, otherC449 Neoplasm of skin F103 Mental dis alcohol withdrawal H335 Retinal detachments I800 Superficial phlebitis legs K279 Peptic ulcerC5099 Neoplasm of breast F119 Mental dis due to opioids H359 Retinal disorder I809 DVT - Deep venous thrombosis K299 GastroduodenitisC579 Neoplasm gynecologic F139 Mental dis due to hypnotics H409 Glaucoma I839 Varicose veins of lower extrem K30 DyspepsiaC61 Neoplasm of prostate F149 Mental dis due to cocaine H431 Vitreous hemorrhage I850 Esophageal varices with bleed K319 Stomach / Duodenum disorderC6299 Neoplasm of testicle F159 Mental dis due stimulants oth H439 Vitreous body disorder I889 Lymphadenitis K358 Appendicitis, acuteC719 Neoplasm of brain unspecified F169 Mental dis due hallucinogens H449 Globe disorder, other I891 Lymphangitis K409 Hernia, inguinalC760 Neoplasm of head, face & neck F189 Mental dis due to solvents H46 Optic neuritis I959 Hypotension K429 Hernia, umbilicalC762 Neoplasm of abdomen F199 Mental dis due multip drug use H532 Diplopia I99 CVS disorder K469 Hernia, abdominal otherC763 Neoplasm of pelvis F209 Schizophrenia H539 Visual disturbance K509 Crohn's diseaseC767 Neoplasm, other F239 Psychotic disorder, acute H571 Ocular pain K519 Ulcerative colitisC900 Multiple myeloma F319 Bipolar affective disorder H579 Eye and adnexa disorder K529 Colitis, noninfectiveC959 Leukemia F329 Depression H609 OE - Otitis externa K559 Intestinal vascular disorderC969 Neoplasm hematologic, other F419 Anxiety disorder H612 Wax in ear K561 IntussusceptionCED-DxS 2015K562 Volvulus Diseases of the MSK system and connective tissueN12 Tubulo-interstitial nephritis Q430 Meckel's diverticulum R99 Other causes mortality T783 Angioneurotic edemaK566 SBO / LBO - Bowel obstruction M0099 Arthritis, septic N139 Obstructive uropathy Q431 Hirschsprung's disease Injury,poisoning and other T784 AllergyK567 Ileus M069 Arthritis, rheumatoid N179 ARF - Acute renal failure Q899 Congenital malformation T009 Sup inj multiple T790 Air embolismK578 Diverticulitis M089 Arthritis, juvenile N189 CRF - Chronic renal failure Q999 Chromosomal abnormality T0190 OW multip, uncompl T791 Fat embolismK579 Diverticulosis M1099 Gout N209 Urinary calculus Symptoms, signs and abnormal findings T0191 OW multip + FB / Infection T793 Post-trauma wound infectionK590 Constipation M1199 Arthropathy, crystal N23 RC - Renal colic R000 Tachycardia T0290 Fx multip, closed T794 Traumatic shockK599 IBS - Functional intestin dis M1399 Arthritis, unspecified N289 Renal and ureteral disease R001 Bradycardia T0291 Fx multip, open T814 Post-op / Procedure infectionK600 Anal fissure, acute M229 Patellar disorder N341 Nonspecific urethritis R002 Palpitations T110 Sup inj upper limb T850 Complication ventricular shuntK603 Anal fistula M239 Internal derangement of knee N390 UTI - Urinary tract infection R040 Epistaxis T111 OW upper limb T859 Complic prosth / implant / graftK612 Anorectal abscess M2509 Hemarthrosis N399 Urinary system disorder R042 Hemoptysis T130 Sup inj lower limb T869 Graft rejectionK613 Ischiorectal abscess M2549 Joint effusion N410 Prostatitis, acute R05 Cough T131 OW lower limb T887 Adverse effect of drugK623 Rectal prolapse M2559 Joint pain N433 Hydrocele R060 SOB - Dyspnea T147 Crushing inj unsp T889 Complic surg / med careK629 Anal / Rectal disorder M2599 Joint disorder N4408 Testicular torsion R061 Stridor T150 FB in corneaK631 Intestinal perforation M300 PAN - Polyarteritis nodosa N4592 Orchitis / Epididymitis R064 Hyperventilation T159 FB on external eyeK639 Intestinal disease, other M303 Kawasaki - Mucocut lymph nd synd N478 Phimosis / Paraphimosis R066 Hiccough T16 FB in earK649 Hemorrhoids M329 SLE - Systemic lupus erythematosus N483 Priapism R074 CP - Chest pain T171 FB in nostrilK650 Peritonitis, acute M349 Scleroderma - Systemic sclerosis N489 Penile disorder R092 Respiratory arrest T179 FB in respiratory tract Provisional CodesK709 Alcoholic liver disease M353 Polymyalgia rheumatica N509 Male genital organs disorder R100 Acute abdomen T181 FB in esophagus U0490 SARS suspectedK729 Hepatic failure M359 Connective tissue disease N63 Breast lump R102 Pelvic and perineal pain T185 FB in anus and rectum Contact with health servicesK739 Hepatitis, chronic M436 Torticollis N649 Breast disorder R104 Abdominal pain / Colic T189 FB in alimentary tract Z016 Radiological exam onlyK746 Cirrhosis (non-alcoholic) of liver M45 Ankylosing spondylitis N739 PID - Pelvic inflammatory dis R111 Nausea alone T190 FB in urethra Z017 Laboratory exam onlyK766 Portal hypertension M4649 Discitis N751 Bartholin's abscess R113 Nausea with vomiting T192 FB in vulva and vagina Z027 Issue of medical certificateK769 Liver disease M4799 Spondylosis N760 Vaginitis, acute R138 Dysphagia T290 Burns multip regions Z040 Blood-alcohol / drug testK8050 Choledocholithiasis M4809 Spinal stenosis N809 Endometriosis R17 Jaundice T301 Burn first degree Z044 Examination after alleged rapeK8080 Biliary colic / Cholelithiasis M4899 Spondylopathy N819 Female genital prolapse R18 Ascites T302 Burn second degree Z046 Legal psychiatric examK810 Cholecystitis, acute M509 Cervical disc disorder N832 Ovarian cysts R208 Paresthesias / Numbness T303 Burn third degree Z094 Cast check / Fracture follow upK8308 Cholangitis M542 Cervicalgia N8350 Torsion ovary R21 Rash T357 Frostbite Z099 Follow-up exam unspec TxK839 Biliary tract disorder M543 Sciatica N899 Noninflamm vaginal disorder R229 Swelling, mass and lump T390 Poisoning salicylates Z209 Contact communicable diseaseK859 Pancreatitis, acute M545 Back pain N926 Irregular menstruation R258 Abn involuntary movements T399 Poisoning acetaminophen Z299 Prophylactic measureK869 Pancreatic disorder M6269 Muscle strain N939 VB - Vaginal bleeding R2688 Gait and mobility abnormality T401 Poisoning heroin Z309 Contraceptive managementK909 Intestinal malabsorption M6299 Muscle disorder, other N946 Dysmenorrhea R300 Dysuria T405 Poisoning cocaine Z349 Pregnancy, normalK919 Postprocedural GI disorder M6599 Synovitis and tenosynovitis Pregnancy, childbirth and the puerperium R318 Hematuria T406 Poisoning narcotics Z37900 Delivery term multip births K922 Gastrointestinal hemorrhage M6659 Spontaneous rupture tendon O009 Ectopic pregnancy R33 Retention of urine T409 Poisoning hallucinogens Z37910 Delivery term single birthK929 Gastrointestinal disorder M702 Olecranon bursitis O021 Retained fetal products R36 Urethral discharge T424 Poisoning benzodiazepines Z38200 Newborn, single birth Dermatologic diseases M704 Prepatellar bursitis O034 Spontaneous abortion, incomplete R398 Urinary system Sx T439 Poisoning psychotropes Z38800 Newborn, multip birthL00 SSSS - Staph scalded skin synd M706 Trochanteric bursitis O039 Spontaneous abortion, complete R400 Altered LOC T469 Poisoning cardiotropes Z439 Stoma careL010 Impetigo M712 Baker's cyst O0899 Complic abortion / Ectopic / Molar R4029 Coma, unspecified T509 Poisoning other substances Z459 Adjustment implanted deviceL029 Abscess / Furuncle / Carbuncle M719 Bursitis, unspecified O15003 Eclampsia in pregnancy R410 Disorientation T510 Toxic effect ethanol Z488 Surgical aftercare evaluationL0300 Paronychia finger M722 Plantar fasciitis O20009 Threatened abortion R42 Dizziness T511 Toxic effect methanol Z5188 Medical care, otherL0301 Paronychia toe M7269 Necrotizing fasciitis O21909 Hyperemesis gravidarum R443 Hallucinations T518 Toxic effect other alcohols Z659 Social problemL039 Cellulitis M751 Rotator cuff syndrome O36999 Maternal care for fetal probl R458 Emotional symptoms / Suicidal ideation T529 Toxic effect solvent Z719 Counselling / Medical adviceL050 Pilonidal cyst with abscess M752 Bicipital tendinitis O47903 False labour R509 Fever T549 Toxic effect corrosive subs Z760 Issue of repeat prescriptionL139 Bullous disorder M754 Impingement synd shoulder O60101 Preterm delivery R51 HA - Headache T569 Toxic effect metal Z769 LWBS / AMA with no DxL211 Seborrheic infantile dermatitis M755 Bursitis of shoulder O75909 Complication of labour and delivery R53 Weakness / Fatigue T58 Toxic effect COL22 Diaper rash M759 Shoulder lesion O99809 Disease of peri-partum R55 Syncope / Vasovagal T599 Toxic effect gases / vapoursL259 Dermatitis, contact M765 Patellar tendonitis Conditions originating in the perinatal period R5609 Febrile convulsions T609 Toxic effect pesticideL299 Pruritus M766 Achilles tendonitis P229 Respir distress of newborn R5688 Seizures / Convulsions T629 Toxic effect noxious foodL309 Dermatitis / Eczema M779 Tendonitis, unspecified P369 Bacterial sepsis of newborn R570 Cardiogenic shock T639 Toxic effect venom animalL409 Psoriasis M7919 Myalgia P38 Omphalitis of newborn R571 Hypovolemic shock T659 Toxic effect substanceL42 Pityriasis rosea M7929 Neuralgia / Neuritis P599 Neonatal jaundice R579 Shock T66 Radiation effectsL509 Urticaria M7969 PLU - Pain in limb unsp P60 DIC of fetus and newborn R58 Hemorrhage T670 Heatstroke and sunstrokeL519 Erythema multiforme M819 Osteoporosis P619 Perinatal hematologic dis R599 Lymphadenopathy T679 Effect heat and lightL52 Erythema nodosum M8429 Fx delayed union P769 Intestinal obstruct newborn R600 Localized edema T68 HypothermiaL600 Ingrown nail M8699 Osteomyelitis P77 Necrotizing enterocol newborn R601 Generalized edema T703 Decompression sicknessL609 Nail disorder M889 Paget's disease of bone P789 Perinatal GI disorder R630 Anorexia T709 BarotraumaL739 Follicular disorder M8999 Bone disease, other P90 Convulsions of newborn R64 Cachexia / Failure to thrive T71 AsphyxiationL84 Corns and callosities M940 Costochondritis P929 Feeding problem of newborn R69 Diagnosis N/A in list  T749 Maltreatment syndrome / AbuseL899 Decubitus (pressure) ulcer M9499 Cartilage disease P95 Fetal death R799 Abn results blood chem T750 Effects lightningL989 Skin disorder Diseases of the genitourinary system P969 Perinatal disorders R938 Abn results imaging T751 Submersion injury (near drowning)N009 Nephritic syndrome, acute Congenital and chromosomal abnormalities R948 Abn results function studies T754 ElectrocutionN049 Nephrotic syndrome Q400 Pyloric stenosis, congenital R95 SIDS - Sudden infant death synd T782 Anaphylactic shock / ReactionN10 PyelonephritisCED-DxS 2015Head and face Thorax Shoulder and upper arm Wrist and hand Thigh and upper legS002 Sup inj periocular area S208 Sup inj thorax S4180 OW shoulder girdle, uncompl S600 Contusion finger(s), not nail S709 Sup inj hip / thighS009 Sup inj head S2190 OW thorax, uncompl S4181 OW shoulder girdle + FB / Infection S601 Contusion finger(s) + nail S7180 OW pelvic girdle, uncomplS0100 OW scalp, uncompl S2191 OW thorax + FB / Infection S42090 Fx clavicle, closed S609 Sup inj wrist / hand S7181 OW pelvic girdle + FB / InfectionS0101 OW scalp + FB / Infection S22090 Fx thoracic vert, closed S42091 Fx clavicle, open S6100 OW finger, not nail, uncompl S72190 Fx hip, closedS0110 OW eyelid, uncompl S22091 Fx thoracic vert, open S42190 Fx scapula, closed S6101 OW finger, not nail + FB / Infection S72191 Fx hip, openS0111 OW eyelid + FB / Infection S22200 Fx sternum, closed S42191 Fx scapula, open S6110 OW finger & nail uncompl S72900 Fx femur, closedS0130 OW ear, uncompl S22201 Fx sternum, open S42290 Fx upper end humerus, closed S6111 OW finger & nail + FB / Infection S72901 Fx femur, openS0131 OW ear + FB / Infection S22300 Fx rib, closed S42291 Fx upper end humerus, open S6190 OW wrist and hand, uncompl S73090 Disloc hipS0150 OW lip / mouth, uncompl S22301 Fx rib, open S42390 Fx shaft humerus, closed S6191 OW wrist and hand + FB / Infection S7319 Sprain / Strain hipS0151 OW lip / mouth + FB / Infection S22490 Fx ribs multip, closed S42391 Fx shaft humerus, open S62000 Fx scaphoid (hand), closed S789 Amputation legS0190 OW head, uncompl S22491 Fx ribs multip, open S42490 Fx lower end humerus, closed S62001 Fx scaphoid (hand), open Lower legS0191 OW head + FB / Infection S22500 Flail chest, closed S42491 Fx lower end humerus, open S62190 Fx other carpal, closed S8190 OW lower leg, uncomplS02100 Fx base skull, closed S22501 Flail chest, open S43090 Disloc shoulder joint S62191 Fx other carpal, open S8191 OW lower leg + FB / InfectionS02101 Fx base skull, open S231 Disloc thoracic vert S43100 Disloc acromioclavicular joint S62290 Fx first metacarp, closed S82000 Fx patella, closedS02200 Fx nasal, closed S259 Inj blood vessel thorax S43200 Disloc sternoclavicular joint S62291 Fx first metacarp, open S82001 Fx patella, openS02201 Fx nasal, open S26800 Contusion heart, no OW S435 Sprain / Strain AC joint S62490 Fx multiple other metacarpals, closed S82400 Fx fibula alone, closedS02300 Fx orbital floor, closed S26801 Contusion heart + OW S4379 Sprain / Strain shoulder S62491 Fx multiple other metacarpals, open S82401 Fx fibula alone, openS02301 Fx orbital floor, open S27200 Hemopneumothorax, tr no OW S489 Amputation arm S62590 Fx thumb, closed S82890 Fx ankle, closedS025 Fx tooth S27201 Hemopneumothorax, tr + OW Forearm S62591 Fx thumb, open S82891 Fx ankle, openS02600 Fx mandible, closed S27300 Contusion lung, no OW S5190 OW forearm, uncomplicated S62690 Fx other finger, closed S82900 Fx lower leg, closedS02601 Fx mandible, open S27301 Contusion lung + OW S52000 Fx olecranon, closed S62691 Fx other finger, open S82901 Fx lower leg, openS02900 Fx skull / facial, closed S27390 Inj lung, no OW S52001 Fx olecranon, open S63090 Disloc wrist S83000 Disloc patellaS02901 Fx skull / facial, open S27391 Inj lung + OW S52100 Fx head radius, closed S63190 Disloc finger S83190 Disloc kneeS030 Dislocation of jaw S27900 Inj intrathoracic organ, no OW S52101 Fx head radius, open S6359 Sprain / Strain wrist S836 Sprain / Strain kneeS0498 Inj cranial nerve S27901 Inj intrathoracic organ + OW S52500 Fx Colles', closed S6369 Sprain / Strain finger S859 Inj blood vessel lower legS050 Corneal abrasion / Inj conjunct S280 Crushed chest S52501 Fx Colles', open S6379 Sprain / Strain hand S8608 Inj Achilles tendonS059 Injury eye / orbit S52900 Fx forearm, closed S6498 Inj nerve wrist / hand S8698 Inj muscle / tendon low legS060 MHI - Concussion Abdominal, pelvis & back S52901 Fx forearm, open S659 Inj blood vessel wrist / hand S878 Crushing inj legS0625 Diffuse brain inj, no OW S3080 Sup inj low back / pelvis S530 Disloc radial head S6698 Inj muscle / tendon hand / wrist S889 Amputation lower legS0626 Diffuse brain inj + OW S3081 Sup inj abdominal wall S53190 Disloc elbow S678 Crushing inj wrist / handS0635 Focal brain inj, no OW S3085 Sup inj genitals S5348 Radial head subluxation (nursemaid's) S681 Amputation finger Foot and ankleS0636 Focal brain inj + OW S31000 OW lower back / pelvis, uncompl S5349 Sprain / Strain elbow S689 Amputation wrist / hand S901 Contusion toe(s), not nailS064 Epidural hemorrhage S31001 OW lower back / pelvis + FB / Infection S579 Crushing inj arm S902 Contusion toe(s) + nailS065 SDH - Traumatic subdural hemorrhage S31190 OW abdominal wall, uncompl S589 Amputation forearm S902 Contusion toe(s) + nailS066 SAH, traumatic S31191 OW abdominal wall + FB / Infection S909 Sup inj ankle / footS081 Amputation ear S31500 OW ext genital organs, uncompl S9130 OW foot, uncomplS092 Rupture ear drum, traumatic S31501 OW ext genital organs + FB / Infection S9131 OW foot + FB / InfectionS32090 Fx lumbar vert, closed S92000 Fx calcaneus, closedS32091 Fx lumbar vert, open S92001 Fx calcaneus, openS32100 Fx sacrum, closed S92100 Fx talus, closedNeck S32101 Fx sacrum, open S92101 Fx talus, openS109 Sup inj neck S32200 Fx coccyx, closed S92290 Fx other tarsal, closedS1190 OW neck, uncompl S32201 Fx coccyx, open S92291 Fx other tarsal, openS1191 OW neck + FB / Infection S32400 Fx acetabulum, closed S92300 Fx metatarsal(s), closedS12900 Fx cervical vert, closed S32401 Fx acetabulum, open S92301 Fx metatarsal(s), openS12901 Fx cervical vert, open S32800 Fx pelvis, closed S92400 Fx great toe, closedS131 Disloc cervical vert S32801 Fx pelvis, open S92401 Fx great toe, openS136 Sprain / Strain cervical spine and neck S331 Disloc lumbar vert S92500 Fx other toe, closedS159 Inj blood vessel at neck S3419 Lesion lumbar spinal cord S92501 Fx other toe, openS3438 Inj cauda equina S92900 Fx foot, closedS359 Inj vascular abd / pelvis S92901 Fx foot, openS36990 Inj intra-abd organ, no OW S93000 Disloc ankle jointS36991 Inj intra-abd organ + OW S93110 Disloc toeS37090 Inj kidney, no OW S93310 Disloc parts footS37091 Inj kidney + OW S9349 Sprain / Strain ankleS37990 Inj pelvic organ, no OW S936 Sprain / Strain footS37991 Inj pelvic organ + OW S978 Crushing inj ankle / footS382 Amputation penis / testicle S981 Amputation toeS3908 Inj muscle / tendon / abd / back / pelvis S984 Amputation footAbbreviation (Eng) DescriptionA acuteabd abdomenabn abnormalAC acromioclavicularAMA against medical adviceARDS - Acute  resp distr synd acute respiratory distress syndromeAV atrioventricular chem chemistryCNS central nervous systemCO carbon monoxidecomplic complicationconjunct conjunctivaCOPD chronic obstructive pulmonary diseaseCVS cardiovascular systemDIC disseminated intravascular coagulationDIC - dissem intravasc coag disseminated intravascular coagulationdis disease / disorderdisloc dislocationDKA diabetic ketoacidosisDM diabetes mellitusDx diagnosisentercol entercolitisext externalextrem extremitiesFB foreign bodyFx fractureGERD - Gastroesoph reflux dis gastroesophageal reflux diseaseGI gastrointestinalheme hematological / hematologicHIV human immunodeficiency virusIBS - Functional intestin dis irritable bowel syndromeinfarct infarctionInj injuryintestin intestinalintox / intoxicat intoxicationintra-abd intra-abdominalisch ischemicITP - Idiop thrombocytopen purpura idiopathic thrombocytopenic purpuraKawasaki - Mucocut lymph nd synd mucocutaneous lymph node syndromeLBO large bowel obstructionLOC level of consciousnesslow lowerLWBS left without being seenmed medicalmetacarp metacarpalMHI mild head injurymultip multipleN/A not availableNoninflamm noninflammatoryobstruct obstructionAbbreviation (Eng) Descriptionoth otherOW open wound (open wound / laceration / puncture)Post-op post-operativePPH - Primary pulm hypertension primary pulmonary hypertensionprobl problemprosth prostheticPSVT - Supraventr tachycardia paroxymal supraventricular tachycardia pulm pulmonaryRespir respiratorySAH subarachnoid hemorrhageSARS suspected severe acute respiratory syndromeSBO small  bowel obstructionSIADH syndrome of inappropriate antidiuretic hormone secretionSOB shortness of breathSSSS - Staph scalded skin synd staphylococcal scalded skin syndromesubs substanceSup inj superficial injury (abrasion / contusion / superficial hematoma)surg surgicalsynd syndromeSx symptom(s)TMJ - Temporomandibr joint dis temporomandibular joint disordertr / trauma traumatictx treatmentuncompl uncomplicatedunsp / unspec unspecifiedURTI upper respiratory tract infectionvenom venomousvert vertebraeAbbreviation (Fr) DetailCE corps etrangerCIVD coagulation intravasculaire disséminéeÉcras écrasementépin. lomb. épinière lombaireext externeFx fractureGEU grossesse extra-utérineHSA hémorragie sous-arachnoïdienneHTA hypertension artérielleIVRS infection des voies respiratoires supérieuresliq céphalo-rachid liquide céphalorachidienMPOC maladie pulmonaire obstructive chroniquePlaie N'importe quelle plaie, lacerationSNC système nerveux centralsup supérieursuperf superficieltrauma traumatisme / traumatiquevert vertébreVIH virus de l’immunodéficience humaine

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