Socioeconomic position and subjective oral health: findings for the adult population in England, Wales and Northern Ireland.

BACKGROUND: The objective of this study was to assess socioeconomic inequalities in subjective measures of oral health in a national sample of adults in England, Wales and Northern Ireland. METHODS: We analysed data from the 2009 Adult Dental Health Survey for 8,765 adults aged 21 years and over. We examined inequalities in three oral health measures: self-rated oral health, Oral Health Impact Profile (OHIP-14), and Oral Impacts on Daily Performance (OIDP). Educational attainment, occupational social class and household income were included as socioeconomic position (SEP) indicators. Multivariable logistic regression models were fitted and from the regression coefficients, predictive margins and conditional marginal effects were estimated to compare predicted probabilities of the outcome across different SEP levels. We also assessed the effect of missing data on our results by re-estimating the regression models after imputing missing data. RESULTS: There were significant differences in predicted probabilities of the outcomes by SEP level among dentate, but not among edentate, participants. For example, persons with no qualifications showed a higher predicted probability of reporting bad oral health (9.1 percentage points higher, 95% CI: 6.54, 11.68) compared to those with a degree or equivalent. Similarly, predicted probabilities of bad oral health and oral impacts were significantly higher for participants in lower income quintiles compared to those in the highest income level (p < 0.001). Marginal effects for all outcomes were weaker for occupational social class compared to education or income. Educational and income-related inequalities were larger among young people and non-significant among 65+ year-olds. Using imputed data confirmed the aforementioned results. CONCLUSIONS: There were clear socio-economic inequalities in subjective oral health among adults in England, Wales and Northern Ireland with stronger gradients for those at younger ages.

Beyond price: individuals' accounts of deciding to pay for private healthcare treatment in the UK.

BACKGROUND: Delivering appropriate and affordable healthcare is a concern across the globe. As countries grapple with the issue of delivering healthcare with finite resources and populations continue to age, more health-related care services or treatments may become an optional 'extra' to be purchased privately. It is timely to consider how, and to what extent, the individual can act as both a 'patient' and a 'consumer'. In the UK the majority of healthcare treatments are free at the point of delivery. However, increasingly some healthcare treatments are being made available via the private healthcare market. Drawing from insights from healthcare policy and social sciences, this paper uses the exemplar of private dental implant treatment provision in the UK to examine what factors people considered when deciding whether or not to pay for a costly healthcare treatment for a non-fatal condition. METHODS: Qualitative interviews with people (n = 27) who considered paying for dental implants treatments in the UK. Data collection and analysis processes followed the principles of the constant comparative methods, and thematic analysis was facilitated through the use of NVivo qualitative data software. RESULTS: Decisions to pay for private healthcare treatments are not simply determined by price. Decisions are mediated by: the perceived 'status' of the healthcare treatment as either functional or aesthetic; how the individual determines and values their 'need' for the treatment; and, the impact the expenditure may have on themselves and others. Choosing a private healthcare provider is sometimes determined simply by personal rapport or extant clinical relationship, or based on the recommendation of others. CONCLUSIONS: As private healthcare markets expand to provide more 'non-essential' services, patients need to develop new skills and to be supported in their new role as consumers.

Commissioning NHS dentistry in England: issues for decision-makers managing the new contract with finite resources.

OBJECTIVES: To explore the views of dental decision-makers in Primary Care Organisations with regard to the management of NHS dental services, and to gauge participants' awareness of economics-based approaches including programme budgeting and marginal analysis, with which to potentially structure commissioning decisions. METHODS: Recorded semi-structured interviews were conducted with 18 NHS dental decision-makers (mixed clinical and finance backgrounds) predominantly across Primary Care Trusts in England. Data were analysed using qualitative methods and the constant comparative approach. RESULTS: Participants were generally involved with contracting rather than commissioning new dental services at the time of interview. It was unclear how oral health needs assessments would guide future resource shifts and how commissioners would ensure the efficient use of finite resources. Whilst many participants thought that economic approaches would assist their commissioning decisions, few participants were aware of programme budgeting and marginal analysis as an alternative economics-based approach. CONCLUSIONS: An assessment of the extent to which finite resources actually maximise the oral health of local populations is timely. Pragmatic economic approaches such as programme budgeting and marginal analysis may offer a framework to guide decision-makers through commissioning and the stages which lie beyond oral health needs assessments.

Explaining time changes in oral health-related quality of life in England: a decomposition analysis.

BACKGROUND: Oral diseases are highly prevalent and impact on oral health-related quality of life (OHRQoL). However, time changes in OHRQoL have been scarcely investigated in the current context of general improvement in clinical oral health. This study aims to examine changes in OHRQoL between 1998 and 2009 among adults in England, and to analyse the contribution of demographics, socioeconomic characteristics and clinical oral health measures. METHODS: Using data from two nationally representative surveys in England, we assessed changes in the Oral Health Impact Profile-14 (OHIP-14), in both the sample overall (n=12 027) and by quasi-cohorts. We calculated the prevalence and extent of oral impacts and summary OHIP-14 scores. An Oaxaca-Blinder type decomposition analysis was used to assess the contribution of demographics (age, gender, marital status), socioeconomic position (education, occupation) and clinical measures (presence of decay, number of missing teeth, having advanced periodontitis). RESULTS: There were significant improvements in OHRQoL, predominantly among those that experienced oral impacts occasionally, but no difference in the proportion with frequent oral impacts. The decomposition model showed that 43% (-4.07/-9.47) of the decrease in prevalence of oral impacts reported occasionally or more often was accounted by the model explanatory variables. Improvements in clinical oral health and the effect of ageing itself accounted for most of the explained change in OHRQoL, but the effect of these factors varied substantially across the lifecourse and quasi-cohorts. CONCLUSIONS: These decomposition findings indicate that broader determinants could be primarily targeted to influence OHRQoL in different age groups or across different adult cohorts.

Learning from contract change in primary care dentistry: A qualitative study of stakeholders in the north of England.

The aim of this research was to explore and synthesise learning from stakeholders (NHS dentists, commissioners and patients) approximately five years on from the introduction of a new NHS dental contract in England. The case study involved a purposive sample of stakeholders associated with a former NHS Primary Care Trust (PCT) in the north of England. Semi-structured interviews were conducted with 8 commissioners of NHS dental services and 5 NHS general dental practitioners. Three focus group meetings were held with 14 NHS dental patients. All focus groups and interviews were audio recorded and transcribed verbatim. The data were analysed using a framework approach. Four themes were identified: 'commissioners' views of managing local NHS dental services'; 'the risks of commissioning for patient access'; 'costs, contract currency and commissioning constraints'; and 'local decision-making and future priorities'. Commissioners reported that much of their time was spent managing existing contracts rather than commissioning services. Patients were unclear about the NHS dental charge bands and dentists strongly criticised the contract's target-driven approach which was centred upon them generating 'units of dental activity'. NHS commissioners remained relatively constrained in their abilities to reallocate dental resources amongst contracts. The national focus upon practitioners achieving their units of dental activity appeared to outweigh interest in the quality of dental care provided.

Introducing high-cost health care to patients: dentists' accounts of offering dental implant treatment.

OBJECTIVES: The decision-making process within health care has been widely researched, with shared decision-making, where both patients and clinicians share technical and personal information, often being cited as the ideal model. To date, much of this research has focused on systems where patients receive their care and treatment free at the point of contact (either in government-funded schemes or in insurance-based schemes). Oral health care often involves patients making direct payments for their care and treatment, and less is known about how this payment affects the decision-making process. It is clear that patient characteristics influence decision-making, but previous evidence suggests that clinicians may assume characteristics rather than eliciting them directly. The aim was to explore the influences on how dentists' engaged in the decision-making process surrounding a high-cost item of health care, dental implant treatments (DITs). METHODS: A qualitative study using semi-structured interviews was undertaken using a purposive sample of primary care dentists (n = 25). Thematic analysis was undertaken to reveal emerging key themes. RESULTS: There were differences in how dentists discussed and offered implants. Dentists made decisions about whether to offer implants based on business factors, professional and legal obligations and whether they perceived the patient to be motivated to have treatment and their ability to pay. There was evidence that assessment of these characteristics was often based on assumptions derived from elements such as the appearance of the patient, the state of the patient's mouth and demographic details. The data suggest that there is a conflict between three elements of acting as a healthcare professional: minimizing provision of unneeded treatment, trying to fully involve patients in shared decisions and acting as a business person with the potential for financial gain. CONCLUSIONS: It might be expected that in the context of a high-cost healthcare intervention for which patients pay the bill themselves, that decision-making would be closer to an informed than a paternalistic model. Our research suggests that paternalistic decision-making is still practised and is influenced by assumptions about patient characteristics. Better tools and training may be required to support clinicians in this area of practice.

Factors affecting patient valuations of caries prevention: Using and validating the willingness to pay method.

OBJECTIVES: Determining the value of, or strength of preference for health care interventions is useful for policy makers in planning health care services. Willingness to pay (WTP) is an established economic technique to determine the strength of preferences for interventions by eliciting monetary valuations from individuals in hypothetical situations. The objective of this study was to elicit WTP values for a dental preventive intervention and to analyze the factors affecting these as well as investigating the validity of the WTP method. METHODS: Patients aged 40 years plus attending dental practices in the UK and Germany were recruited on a consecutive basis over one month. Participants received information about a novel root caries prevention intervention. They then completed a questionnaire including a WTP task. Where the coating was indicated, patients were offered this for a payment and acceptance was recorded. Analysis included econometric modelling and comparison of expected (based on stated WTP) versus actual behaviour. RESULTS: The mean WTP for the coating was £96.41 (standard deviation 60.61). Econometric models showed that no demographic or dental history factors were significant predictors of WTP. 63% of the sample behaved as expected when using stated WTP to predict whether they would buy the coating. The remainder were split almost equally between those expected to pay but who did not and those who were expected to refuse but paid. CONCLUSIONS: Values for a caries preventive intervention had a large and unpredictable variance. In comparing hypothetical versus real preferences both under- and over-valuation occurs. CLINICAL SIGNIFICANCE: Wide and unpredictable variation in valuations for prevention may mean that there are difficult policy questions around what resource should be allocated to dental prevention and how to target this resource.

Interpreting oral health-related quality of life data.

The most common way of presenting data from studies using quality of life or patient-based outcome (PBO) measures is in terms of mean scores along with testing the statistical significance of differences in means. We argue that this is insufficient in and of itself and call for a more comprehensive and thoughtful approach to the reporting and interpretation of data. PBO scores (and their means for that matter) are intrinsically meaningless, and differences in means between groups mask important and potentially different patterns in response within groups. More importantly, they are difficult to interpret because of the absence of a meaningful benchmark. The minimally important difference (MID) provides that benchmark to assist interpretability. This commentary discusses different approaches (distribution-based and anchor-based) and specific methods for assessing the MID in both longitudinal and cross-sectional studies, and suggests minimum standards for reporting and interpreting PBO measures in an oral health context.

Effect of a 1-month vs. a 12-month reference period on responses to the 14-item Oral Health Impact Profile.

The length of the reference period used in surveys of subjective oral health may have a marked influence on the responses obtained. We aimed to evaluate the effect of a 1-month (RP-1) vs. a 12-month (RP-12) reference period in the Oral Health Impact Profile (OHIP-14) questionnaire. Using a randomized cross-over design, RP-1 and RP-12 OHIP-14 questionnaires were administered, 1 month apart, to two samples of Finnish adults, namely people awaiting orthognathic surgery (n = 104) and non-patient workers (n = 111). The effect of the reference period was computed by subtracting RP-1 OHIP-14 severity scores from RP-12 OHIP-14 severity scores (DeltaRP). Potential order effects were assessed by comparing DeltaRP between groups completing the RP-1 vs. the RP-12 questionnaire first. Mean OHIP-14 severity scores were slightly higher when the RP-12 questionnaire was administered first, but mean DeltaRP values were below the value of 2.5 considered clinically meaningful, and all 95% confidence intervals for DeltaRP included zero. No order effects in the OHIP-14 severity scores were observed. Therefore, although a standardized reference period of 12 months is recommended, in population surveys the use of a shorter reference period does not appear to influence responses.