Robot-assisted pelvic and renal surgery compared with laparoscopic or open surgery: Literature review of cost-effectiveness and clinical outcomes.

BACKGROUND AND AIM: The purpose of this study was to evaluate clinical experiences and cost-effectiveness by comparing robot-assisted surgery with laparoscopic- or open surgery for pelvic and renal operations. METHODS: A narrative review was carried out. RESULTS: When using robotic-assisted surgery, oncological and functional results are similar to after laparoscopic or open surgery. One exception may be a shorter survival in cancer of the cervix uteri. In addition, postoperative complications after robotic-assisted surgery are similar, bleeding and transfusion needs are less, and the hospital stay is shorter but the preparation of the operating theater before and after surgery and the operation times are longer. Finally, robot-assisted surgery has, in several studies, been reported to be not cost-effective primarily due to high investment costs. However, more recent studies provide improved cost-effectiveness estimates due to more effective preparation of the operating theater before surgery, improved surgeon experience, and decreased investment costs. CONCLUSIONS: Complications and functional and oncological outcomes after robot-assisted surgery are similar to open surgery and laparoscopic surgery. The cost-effectiveness of robot-assisted surgery is likely to equal or surpass the alternatives.

Identifying latent themes in suicide among black and white adolescents and young adults using the National Violent Death Reporting System, 2013-2019.

Suicide rates for adolescents and young adults (AYA) have risen dramatically in recent years - by almost 60% for Americans aged 10-24 years between 2007 and 2018. This increase has occurred for both whites and Blacks, with the rise in suicide among Black youth of particular note. Blacks historically exhibit lower rates of suicide relative to whites and thus, less is known about the etiology of Black suicide. To gain insight into the underlying causes of suicide among AYA, we examine medical examiner reports from the National Violent Death Reporting System (NVDRS) from 2013 to 2019 for over 26,000 Black and white suicide decedents ages 10-29. We apply structural topic modeling (STM) approaches to describe the broad contours of AYA suicide in the United States today. Our findings reveal distinct patterns by race. Guns, violence and the criminal justice system are prominent features of Black suicide, whether through the mechanism used in the suicide, either by firearm or other violent means such as fire or electrocution, the existence of criminal or legal problems/disputes, the location of death in a jail, or the presence of police. In contrast, the narratives of white AYA are more likely to reference mental health or substance abuse problems. Access to resources, as measured by county median household income, overlay these patterns. Themes more prevalent among Blacks are more common in poorer counties; those more prevalent among whites tend to be more common in wealthier counties. Our findings are consistent with other studies that suggest Black people experience greater exposure to violence and other traumas, systemic racism and interpersonal discrimination that may elevate the risk for suicidal behavior.

Cost-effectiveness of root canal treatment compared with tooth extraction in a Swedish Public Dental Service: A prospective controlled cohort study.

OBJECTIVES: To evaluate the cost-effectiveness of root canal treatment (RCT) compared with a tooth extraction in a general dental practice setting, with reference to cost per quality-adjusted life-year (QALY) gained over 1 year. MATERIAL AND METHODS: This is a prospective controlled cohort study based on patients either starting RCT or undergoing extraction at one of six Public Dental Service clinics in the county of Västra Götaland, Sweden. From a total of 65 patients, 2 comparable groups were formed: 37 started RCT and 28 underwent extraction. A societal perspective was used for the cost calculations. QALYs were estimated, based on the EQ-5D-5L given to the patients at their first treatment appointment and then after 1, 6, and 12 months. RESULTS: The total mean cost of RCT ($689.1) was higher than for extraction ($280.1). For those patients whose extracted tooth was replaced, the costs were even higher ($1245.5). There were no significant intergroup differences in QALYs, but a significant improvement in health state values in the tooth-preserving group. CONCLUSIONS: In the short term, extraction was cost-effective compared with preserving a tooth with RCT. However, the potential need for future replacement of the extracted tooth, by an implant, fixed prosthesis, or removable partial dentures, may change the calculation in favor of RCT.

A cost analysis of orthodontic space closure and implant treatment in patients missing maxillary lateral incisors with a long-term perspective.

OBJECTIVE: Few studies within orthodontics present both economic and clinical findings. Missing maxillary lateral incisors is a frequently occurring anomaly. The treatment alternatives most used are orthodontic space closure and prosthetic replacement of the missing tooth. Our aim is to compare the total societal costs of orthodontic space closure (SC) and implant therapy (IT) in patients missing maxillary lateral incisors. METHODS: Records of 32 patients treated with SC (n = 18) or IT (n = 14) due to missing maxillary lateral incisors were retrieved from the archives. Direct costs and indirect costs in the short- and long-term were analysed using a cost analysis with a societal perspective up of to 12 years post-treatment. RESULTS: Comparing cases treated with SC and IT, the difference in direct short-term costs for treatment is €735.54, whereas SC is the least costly. There is no difference between SC and IT in short-term parent loss of productivity, long-term loss of productivity, costs for transportation, or direct long-term costs. A difference was found between SC and IT-in favour of SC-when comparing patients' loss of productivity (P = 0.007), short-term societal costs (P < 0.001), long-term societal costs (P = 0.037), and total societal costs (P < 0.001). LIMITATIONS: There is a limited number of patient records. Local factors such as subsidies, urban versus rural areas, taxes, etc. can influence monetary variables, so the transferability to other settings may be limited. CONCLUSION: Patients treated with SC have a lower total societal cost compared to patients treated with IT. There was a difference in productivity loss for patients between SC and IT; however, concerning other indirect parameters and direct long-term costs, there was no difference between the two treatments.

Cost-effectiveness of different exercise intensities during oncological treatment in the Phys-Can RCT.

BACKGROUND: Cost-effectiveness is important in the prioritisation between interventions in health care. Exercise is cost-effective compared to usual care during oncological treatment; however, the significance of exercise intensity to the cost-effectiveness is unclear. In the present study, we aimed to evaluate the long-term cost-effectiveness of the randomised controlled trial Phys-Can, a six-month exercise programme of high (HI) or low-to-moderate intensity (LMI) during (neo)adjuvant oncological treatment. METHODS: A cost-effectiveness analysis was performed, based on 189 participants with breast, colorectal, or prostate cancer (HI: n = 99 and LMI: n = 90) from the Phys-Can RCT in Sweden. Costs were estimated from a societal perspective, and included cost of the exercise intervention, health care utilisation and productivity loss. Health outcomes were assessed as quality-adjusted life-years (QALYs), using EQ-5D-5L at baseline, post intervention and 12 months after the completion of the intervention. RESULTS: At 12-month follow-up after the intervention, the total cost per participant did not differ significantly between HI (€27,314) and LMI exercise (€29,788). There was no significant difference in health outcome between the intensity groups. On average HI generated 1.190 QALYs and LMI 1.185 QALYs. The mean incremental cost-effectiveness ratio indicated that HI was cost effective compared with LMI, but the uncertainty was large. CONCLUSIONS: We conclude that HI and LMI exercise have similar costs and effects during oncological treatment. Hence, based on cost-effectiveness, we suggest that decision makers and clinicians can consider implementing both HI and LMI exercise programmes and recommend either intensity to the patients with cancer during oncological treatment to facilitate improvement of health.

Long-term resource utilisation and associated costs of exercise during (neo)adjuvant oncological treatment: the Phys-Can project.

BACKGROUND: Exercise during oncological treatment is beneficial to patient health and can counteract the side effects of treatment. Knowledge of the societal costs associated with an exercise intervention, however, is limited. The aims of the present study were to evaluate the long-term resource utilisation and societal costs of an exercise intervention conducted during (neo)adjuvant oncological treatment in a randomised control trial (RCT) versus usual care (UC), and to compare high-intensity (HI) versus low-to-moderate intensity (LMI) exercise in the RCT. METHODS: We used data from the Physical Training and Cancer (Phys-Can) project. In the RCT, 577 participants were randomised to HI or to LMI of combined endurance and resistance training for 6 months, during oncological treatment. The project also included 89 participants with UC in a longitudinal observational study. We measured at baseline and after 18 months. Resource utilisation and costs of the exercise intervention, health care, and productivity loss were compared using analyses of covariance (RCT vs. UC) and t test (HI vs. LMI). RESULTS: Complete data were available for 619 participants (RCT HI: n = 269, LMI: n = 265, and UC: n = 85). We found no difference in total societal costs between the exercise intervention groups in the RCT and UC. However, participants in the RCT had lower rates of disability pension days (p < .001), corresponding costs (p = .001), and pharmacy costs (p = .018) than the UC group. Nor did we find differences in resource utilisation or costs between HI and LMI exercise int the RCT. CONCLUSION: Our study showed no difference in total societal costs between the comprehensive exercise intervention and UC or between the exercise intensities. This suggests that exercise, with its well-documented health benefits during oncological treatment, produces neither additional costs nor savings.

Long-Term Cost-Effectiveness through the Dental-Health FRAMM Guideline for Caries Prevention.

A guideline called FRAMM, which is an acronym in Swedish for the most important parts of this guideline, namely "fluoride", "advice", "arena", "motivation" and "diet", was implemented in 2008 in the Västra Götaland Region in Sweden. This guideline included fluoride varnish applications performed at school twice a year at six-monthly intervals for all 12- to 15-year-olds, together with lessons on oral health. The aim of this analysis was to estimate the long-term cost-effectiveness, using prognostic calculations, of the FRAMM Guideline for 12- to 15-year-olds, compared with routine care, until the participants were 23 years old. A cost-effectiveness analysis was performed from a health care perspective, based on four years of verified data and seven years of prognosis. Data from FRAMM were combined with cost data from price lists in Sweden. The cost-effectiveness was analyzed by relating the difference in costs to the difference in the number of approximal surfaces with fillings and/or dentin lesions (DFSa). The analysis shows that FRAMM was considered dominant compared to the controls in all alternative scenarios, hence costs were prognosed to be lowered and outcomes were prognosed to be improved. A dental health program like the FRAMM Guideline with fluoride varnish during the caries risk period from 12 to 15 years is predicted to be cost-effective in the longer perspective. To further study the actual long-term caries increment after a preventive dental health program would be of great interest to verify these results.

Impact of socio-economic status and race on emergency hospital admission outcomes: Analysis from hospital admissions between 2001 and 2012.

Socio-economic and racial/ethnic disparities in healthcare quality have been the point of huge discussion and debate. There is currently a public debate over healthcare legislation in the United States to eliminate the disparities in healthcare. We reviewed the literature and critically examined standard socio-economic and racial/ethnic measurement approaches. As a result of the literature review, we identified and discussed the limitations in existing quality assessment for identifying and addressing these disparities. The aim of this research was to investigate the difference between health outcomes based on patients' ability to pay and ethnic status during a single emergency admission. We conducted a multifactorial analysis using the 11-year admissions data from a single hospital to test the bias in short-term health outcomes for length of stay and death rate, based on 'payment type' and 'race', for emergency hospital admissions. Inconclusive findings for racial bias in outcomes may be influenced by different insurance and demographic profiles by race. As a result, we found that the Self-Pay (no insurance) category has the shortest statistically significant length of stay. While the differences between Medicare, Private and Government are not significant, Self-Pay was significantly shorter. That 'Whites' have more Medicare (older) patients than 'Blacks' might possibly lead to a longer length of stay and higher death rate for the group.

Cost analysis of prosthetic rehabilitation in young patients with Amelogenesis imperfecta.

OBJECTIVES: Children and adolescents with amelogenesis imperfecta (AI) have extensive treatment needs, but costs have not been explored previously. We calculated the costs of prosthetic rehabilitation and analyzed whether costs of treatment begun in early adolescence are lower compared with in early adulthood. METHODS: Data from the dental records of 25 patients with AI and 25 age- and sex-matched controls were analyzed. Patients were followed for a mean period of 12.3 ± 1.5 years. Number of dental visits, dental treatment costs, and indirect costs were calculated during three time periods, before, during and after prosthetic therapy. Swedish national reference prices for general and specialist dental care were used. RESULTS: The mean number of visits was significantly higher in the AI group: 43.3 ± 19.7 (controls: 17.5 ± 19.8; p < .001). Mean total costs were 8.5 times higher for patients with AI: €16,257 ± 5,595 (controls: €1,904 ± 993). Mean number of crowns made in patients with AI was 12 ± 7 (range 1 - 31). Indirect costs were significantly higher in the AI group and constituted 22% of the total costs. After crown therapy, costs between groups ceased to differ significantly. Calculations of total costs in the hypothetical scenario (discount rate at 3% annually) were €18,475 for prosthetic rehabilitation began at age 12 years compared with €20,227 if treatment began at 20 years of age. CONCLUSIONS: Prosthetic rehabilitation costs for children and adolescents with AI can be high. Early crown therapy is associated with lower costs and a lower number of dental visits. CLINICAL IMPLICATIONS: Early crown therapy in children and adolescents with severe AI is a cost-reducing treatment associated with few complications and reduced need of dental care during adolescence compared with treatment begun at age 20.

There is a paucity of economic evaluations of prediction methods of caries and periodontitis-A systematic review.

OBJECTIVES: Direct cost for methods of prediction also named risk assessment in dentistry may be negligible compared with the cost of extensive constructions. On the other hand, as risk assessment is performed daily and for several patients in general dental practice, the costs may be considerable. The objective was to summarize evidence in studies of economic evaluation of prognostic prediction multivariable models and methods of caries and periodontitis and to identify knowledge gaps (PROSPERO registration number: CRD42020149763). MATERIAL AND METHODS: Four electronic databases (PubMed, Web of Science, The Cochrane Library, NHS Economic Evaluation Database) and reference lists of included studies were searched. Titles and abstracts were screened by two reviewers in parallel. Full-text studies reporting resources used, costs and cost-effectiveness of prediction models and methods were selected and critically appraised using a protocol based on items from the CHEERS checklist for economic evaluations and the CHARMS checklist for evaluation of prediction studies. RESULTS: From 38 selected studies, six studies on prediction fulfilled the eligibility criteria, four on caries and two on periodontitis. As the economic evaluations differed in method and perspective among the studies, the results could not be generalized. Our systematic review revealed methodological shortcomings regarding the description of predictive models and methods, and particularly of the economic evaluation. CONCLUSIONS: The systematic review highlighted a paucity of economic evaluations regarding methods or multivariable models for prediction of caries and periodontitis. Our results indicate that what we currently practice using models and methods to predict caries and periodontitis lacks evidence regarding cost-effectiveness.

Cost-effectiveness of caries preventive interventions - a systematic review.

OBJECTIVE: The primary purpose of this study was to assess the cost-effectiveness of caries preventive interventions. MATERIAL AND METHODS: A systematic review was conducted, following the PRISMA Statement. Four electronic databases were searched (final search 16 March 2020). Studies fulfilling the inclusion criteria were independently critically appraised, by two reviewers in parallel. Data from each included study were extracted and tabulated: the analysis used a narrative approach to present the results of the estimated cost-effectiveness. RESULTS AND CONCLUSIONS: Twenty-six publications fulfilled the inclusion criteria and were of low or moderate risk of bias. Ten publications were economic evaluations, directly based on empirical studies, and the other 16 were modelling studies. Most of the studies concerned interventions for children and the most common were analyses of fluoride varnish and risk-based programs. Some of the studies showed both reduced cost and improved outcomes, but most studies reported that the improved outcome came with an additional cost. The results disclosed several cost-effectiveness evaluations of caries preventive interventions in the literature, but these target primarily children at high risk. There is a scarcity of studies specifically targeting adults and especially the elderly.

The costs of human uterus transplantation: a study based on the nine cases of the initial Swedish live donor trial.

STUDY QUESTION: What are the costs of live donor uterus transplantation in a European setting? SUMMARY ANSWER: The total costs for preoperative investigations, including IVF, and live donor uterus transplantation including postoperative costs for 2 months, were calculated to be €74 564 (mean), with the costs of recipient being somewhat higher than for donor and the cost components of total costs distributed between sick leave (25.7%), postoperative hospitalization (17.8%), surgery (17.1%), preoperative investigations (15.7%), anaesthesia (9.7%), drugs (7.8%), tests after surgery (4.0%) and for re-hospitalization (2.2%). WHAT IS KNOWN ALREADY: Uterus transplantation has proved to be successful by demonstrations of live births, both after live donor and deceased donor procedures. The transplantation is considered as a complex and expensive infertility treatment. There exist no analyses of costs involved in uterus transplantation. STUDY DESIGN, SIZE, DURATION: This prospective cohort study included nine uterus transplantations procedures, performed in Sweden in 2013. Study duration of this health economic study included 6-12 months of pre-transplantation investigations and the time interval from transplantation to 2 months after. PARTICIPANTS/MATERIALS, SETTING, METHODS: Nine triads of uterus recipient, partner of recipient and uterus donor participated. All prospective recipients were in stable relationships and performed IVF with their partners before transplantation. The nine donors were relatives or family friends. The recipients and donors underwent pre-transplantation investigations with imaging, laboratory tests and psychological/medical screening prior to transplantation. Transplantation was by laparotomy in both donor and recipient. Standard immunosuppression and postoperative medication were used. After discharge from the hospital, the recipients were followed frequently with laboratory tests and examinations. MAIN RESULTS AND THE ROLE OF CHANCE: The mean costs for preoperative investigations, including IVF, and live donor uterus transplantation with postoperative costs for 2 months, were calculated to be €74 564 (range €50 960-€99 658), from a societal perspective. The four largest components were cost of sick leave (€19 164), cost of postoperative hospitalization (€13 246), surgery cost (€12 779) and costs for preoperative investigations, including IVF (€11 739). Smaller components were costs for anaesthesia (€7207), costs for drugs (€5821), costs for post-surgical tests (€2985) and costs for re-hospitalization (€1623). The costs of the recipient (€42 984) were somewhat higher than the costs of the donor (€31 580), but in terms of costs, they should be viewed as one entity. By using a health care perspective, excluding cost for productivity loss, the total costs would be reduced by 26%. LIMITATIONS, REASONS FOR CAUTION: A limitation is the restricted sample size and that this is in the experimental, clinical stage of development. WIDER IMPLICATIONS OF THE FINDINGS: The results provide the first information concerning the costs for pre-transplantation investigations and uterus transplantation procedures with postoperative follow-up. We consider the total estimate to be in the higher interval, because of the extensive research protocol. It is likely that the cost of live donor uterus transplantation will vary between countries and that the costs will be lower in a future clinical setting. STUDY FUNDING/COMPETING INTEREST(S): Funding was received from the Jane and Dan Olsson Foundation for Science; the Knut and Alice Wallenberg Foundation; an ALF grant from the Swedish state under an agreement between the government and the county councils; and the Swedish Research Council. None of the authors have a conflict of interest with regard to the study. TRIAL REGISTRATION NUMBER: NCT01844362.

Costs and health-related quality of life in relation to caries.

BACKGROUND: Dental caries remains a common and expensive disease for both society and affected individuals. Furthermore, caries often affect individuals' health-related quality of life (HRQoL). Health economic evaluations are needed to understand how to efficiently distribute dental care resources. This study aims to evaluate treatment costs and QALY weights for caries active and inactive adult individuals, and to test whether the generic instrument EQ-5D-5 L can distinguish differences in this population. METHODS: A total of 1200 randomly selected individuals from dental clinics in Västerbotten County, Sweden, were invited to participate. Of these, 79 caries active and 179 caries inactive patients agreed to participate (response rate of 21.7%). Inclusion criteria were participants between 20 and 65 years old and same caries risk group categorization in two consecutive check-ups between 2014 and 2017. RESULTS: Treatment costs showed to be twice as high in the caries active group compared to the caries inactive group and were three times higher in the caries active age group 20-29 compared to the caries inactive age group 20-29. Differences between the groups was found for number of intact teeth according to age groups. In the EQ-5D-5 L instrument, more problems relating to the dimension anxiety/depression was seen in the caries active group. QALY weights showed tendencies (non-significant) to be lower in the caries active group. CONCLUSIONS: These findings highlight the need for efficient treatments and prevention strategies as well as adequate money allocation within dentistry. However, further research is needed to assess appropriate instruments for health economic evaluations.

Willingness to pay for osteoporosis risk assessment in primary dental care.

BACKGROUND: Fragility fracture related to osteoporosis among postmenopausal women is a significant cause of morbidity. The care and aftercare of these fractures are associated with substantial costs to society. A main problem is that many individuals suffer from osteoporosis without knowing it before a fracture happens. Dentists may have an important role in early identification of individuals with osteoporosis by assessment of dental radiographs already included in the dental examination. The aim of this study was therefore to investigate postmenopausal women's preferences for an osteoporosis risk assessment in primary dental care. RESULTS: Most respondents (129 of 144 (90%)) were willing to pay for an osteoporosis risk assessment in primary dental care. The overall mean willingness to pay (WTP) including respondents that denoted none or zero WTP was 44.60 € (CI 95% 38.46-50.74 €) (median 34.75 €). A majority (80.6%) of the respondents that denoted WTP also gave a motivation for their answer. The two most common reasons denoted for being willing to pay for osteoporosis risk assessment were the importance of early diagnosis and preventive care to avoid fractures (41.0%) and the importance of knowledge of a risk of osteoporosis (26.4%). A majority of respondents (67.8%) considered it valuable if dental clinics would offer osteoporosis risk assessment. CONCLUSIONS: Postmenopausal women seem to find it valuable to be offered osteoporosis risk assessment in primary dental care and are willing to pay for such a risk assessment. From a societal perspective early diagnosis of osteoporosis by risk assessment in primary dental care could prevent osteoporotic related fractures and benefit women's health and quality of life, as well as have a major impact on the health-care budget in terms of cost-savings.

Cost-effectiveness of pulp capping and root canal treatment of young permanent teeth.

OBJECTIVE: To contribute with information on cost-effectiveness of pulp capping and root canal treatment of posterior permanent vital teeth in children and adolescents with pulp exposures due to caries. MATERIAL AND METHODS: Cost-effectiveness by means of a Markov simulation model was studied in a Scandinavian setting. In a simulated 12-year-old patient, treatment of pulpal exposure of a permanent tooth, either by the initial treatment pulp capping or root canal treatment, was followed for 9 years until the patient was 21. The model was based on outcome data obtained from published literature and cost data based on reference prices. RESULTS: In the simulated case, with the annual failure probalility (AFP) of 0.034 for pulp capping, the total cost for an initial treatment with pulp capping and any anticipated following treatments during the 9 years, was 367 EUR lower than for a root canal treatment as the initial treatment. After an initial treatment with pulp capping 10.4% fewer teeth, compared with initial root canal treatment, were anticipated to be extracted. Pulp capping was thus considered to be the cost-effective alternative. The sensitivity analyses showed that the AFP of a tooth requiring a root canal treatment after an initial pulp capping needed to be 0.2 before root canal treatment may be considered being the cost-effective treatment. CONCLUSIONS: This model analysis indicated initial treatment by pulp capping to be cost-effective compared to root canal treatment in children and adolescents with pulp exposures due to caries.

Economic evaluation of an expanded caries-preventive program targeting toddlers in high-risk areas in Sweden.

OBJECTIVE: To economically evaluate a caries-preventive program "Stop Caries Stockholm" (SCS) where a standard program is supplemented with biannual applications of fluoride varnish in toddlers and compared it with the standard preventive program. MATERIAL AND METHODS: Data from the cluster randomized controlled field trial SCS including 3403 children, conducted in multicultural areas with low socioeconomic status was used. The difference in mean caries increment between the examinations; when the toddlers were 1 and 3 years old, was outcome measure of the intervention. The program was evaluated from a societal as well as a dental health care perspective. The incremental cost-effectiveness ratio (ICER) was calculated as the incremental cost for each defs prevented. RESULTS: Average dental health care costs per child at age 3 years were EUR 95.77 for the supplemental intervention and EUR 70.52 for the standard intervention. The ICER was EUR 280.56 from a dental health care perspective and EUR 468.67 and considered high. CONCLUSIONS: The supplemental caries intervention program was not found to be cost-effective. The program raised costs without significantly reducing caries development. A better alternative use of the resources is recommended. TRIAL REGISTRATION: www.controlled-trials.com (ISRCTN35086887).

A 1-year perspective on goal-directed therapy in elderly with hip fracture: Secondary outcomes.

BACKGROUND: We have previously reported inconclusive results from a randomized controlled trial in elderly with hip-fracture comparing intra-operative goal-directed therapy with routine fluid treatment. Now we aimed to describe and compare secondary outcomes at 4 months and 1 year follow-up and to analyze the cost-effectiveness. METHODS: Patients with hip fracture (age ≥70) were randomized for GDT or routine fluid treatment (RFT). The secondary outcomes were long-term survival, complications, number of hospital readmissions, and quality of life (EQ-5D) changes. Additionally, cost effectiveness was analyzed by an analytic tool which combines the clinical effectiveness, quality of life changes and costs. RESULTS: Patient data (GDT n = 74; RFT n = 75) were analyzed on an intention to treat basis. Statistically significant differences (GDT vs RFT) were not found considering survival (RR 0.76, 95%CI 0.45-1.28) and complications (RR 0.68, 95% CI 0.4-1.10) at 12 months. No statistically significant difference was found between hospital readmissions and quality of life changes. CONCLUSION: The statistical uncertainty of risk reduction of negative outcomes and the large variability of the collected data indicate the need of further research in large sample sizes. To enable future health economic evaluation for decision support surrounding implementation of GDT, we suggest adding patient-oriented outcomes in future trials.

Cost-Effectiveness through the Dental-Health FRAMM Guideline for Caries Prevention among 12- to 15-Year-Olds in Sweden.

Since 2008, FRAMM has been a guideline for caries prevention for all 3- to 15-year-olds in the Västra Götaland Region in Sweden and a predominant part is school-based fluoride varnish applications for all 12- to 15-year-olds. The aims were to evaluate dental health-economic data among 12- to 15-year-olds, based on the approximal caries prevalence at the age of 12, and to evaluate cost-effectiveness. Caries data for 13,490 adolescents born in 1993 who did not take part and 11,321 adolescents born in 1998 who followed this guideline were extracted from dental records. Those with no dentin and/or enamel caries lesions and/or fillings on the approximal surfaces were pooled into the "low" subgroup, those with 1-3 into the "moderate" subgroup and those with ≥4 into the "high" subgroup. The results revealed that the low subgroup had a low approximal caries increment compared with the moderate and high subgroups during the 4-year study period. In all groups, there were statistically significant differences between those who took part in the guideline and those who did not. The analysis of cost-effectiveness revealed the lowest incremental cost-effectiveness ratio (ICER) for the high subgroup for decayed and/or filled approximal surfaces (DFSa) and approximal enamel lesions together and the highest ICER for the low subgroup for DFSa alone. To conclude, the FRAMM Guideline reduced the caries increment for adolescents with low, moderate and high approximal caries prevalence. The subgroup with the most favourable cost-effectiveness comprised those with a high caries prevalence at the age of 12.

Effects and cost-effectiveness of postoperative oral analgesics for additional postoperative pain relief in children and adolescents undergoing dental treatment: Health technology assessment including a systematic review.

BACKGROUND: There is an uncertainty regarding how to optimally prevent and/or reduce pain after dental treatment on children and adolescents. AIM: To conduct a systematic review (SR) and health technology assessment (HTA) of oral analgesics administered after dental treatment to prevent postoperative pain in children and adolescents aged 3-19 years. DESIGN: A PICO-protocol was constructed and registered in PROSPERO (CRD42017075589). Searches were conducted in PubMed, Cochrane, Scopus, Cinahl, and EMBASE, November 2018. The researchers (reading in pairs) assessed identified studies independently, according to the defined inclusion and exclusion criteria, following the PRISMA-statement. RESULTS: 3,963 scientific papers were identified, whereof 216 read in full text. None met the inclusion criteria, leading to an empty SR. Ethical issues were identified related to the recognized knowledge gap in terms of challenges to conduct studies that are well-designed from methodological as well as ethical perspectives. CONCLUSIONS: There is no scientific support for the use or rejection of oral analgesics administered after dental treatment in order to prevent or reduce postoperative pain in children and adolescents. Thus, no guidelines can be formulated on this issue based solely on scientific evidence. Well-designed studies on how to prevent pain from developing after dental treatment in children and adolescents is urgently needed.

Discrepancy between Health Care Rationing at the Bedside and Policy Level.

BACKGROUND: Whether doctors at the bedside level should be engaged in health care rationing is a controversial topic that has spurred much debate. From an empirical point of view, a key issue is whether there exists a behavioral difference between rationing at the bedside and policy level. Psychological theory suggests that we should indeed expect such a difference, but existing empirical evidence is inconclusive. OBJECTIVE: To explore whether rationing decisions taken at the bedside level are different from rationing decisions taken at the policy level. METHOD: Behavioral experiment where participants ( n = 573) made rationing decisions in hypothetical scenarios. Participants (medical and nonmedical students) were randomly assigned to either a bedside or a policy condition. Each scenario involved 1 decision, concerning either a life-saving medical treatment or a quality-of-life improving treatment. All scenarios were identical across the bedside and policy condition except for the level of decision making. RESULTS: We found a discrepancy between health care rationing at policy and bedside level for scenarios involving life-saving decisions, where subjects rationed treatments to a greater extent at the policy level compared to bedside level (35.6% v. 29.3%, P = 0.001). Medical students were more likely to ration care compared to nonmedical students. Follow-up questions showed that bedside rationing was more emotionally burdensome than rationing at the policy level, indicating that psychological factors likely play a key role in explaining the observed behavioral differences. We found no difference in rationing between bedside and policy level for quality-of-life improving treatments (54.6% v. 55.7%, P = 0.507). CONCLUSIONS: Our results indicate a robust "bedside effect" in the life-saving domain of health care rationing decisions, thereby adding new insights to the understanding of the malleability of preferences related to resource allocation.