Costs of dental care and its financial impacts on patients in a population with low availability of services.

OBJECTIVES: To determine the direct and indirect costs of accessing and utilizing dental services in Tanzania and the proportion of patients experiencing economic burden due to treatment costs. BASIC RESEARCH DESIGN: Survey of 489 dental patients utilizing an out-of-pocket payment modality was carried out in four regional hospitals. Direct and indirect costs for service utilization were calculated. Financial expenditures were used to assess significant financial impacts of utilization of dental services on household economies. RESULTS: Direct costs comprised 80% of the total treatment costs, whereas indirect costs comprised 20%. About half of the patients experienced significant financial impacts as a result of their utilization of dental services. Proportionately more patients from low-income households (92.2%) experienced significant financial impacts. Most patients attended the clinics due to toothache and the most widely expected treatment was dental extraction. Only 7.1% of the patients received a filling. The costs for dental restorations were three-times those for tooth extraction. CONCLUSIONS: Dental service utilization leads to significant financial impacts on many of the households in this setting. Increasing the rate of prepayment for health services and reducing income inequality may help to mitigate these impacts.

Patients' willingness to pay for dental services in a population with limited restorative services.

OBJECTIVES: To determine and compare patients' willingness-to-pay (WTP) for tooth extraction and filling services in Tanzania and to assess the socio-demographic factors that are associated with such valuations. METHODS: Contingent valuation survey utilizing an open-ended willingness-to-pay format was administered among 1522 outpatients in four regional hospitals in Tanzania. WTP for extraction and tooth filling services for various tooth categories were determined and compared using Mann-Whitney and Kruskal-Wallis tests. The association of WTP values with socio-demographic background factors was assessed using multiple regression analysis. RESULTS: The mean WTP amounts for tooth filling were Tanzania shillings (Tshs) 7,398 (3.4 US$) and Tshs 7,726 (3.5 US$) for anterior and posterior teeth respectively. The mean WTP for tooth filling services was lower than the average charged fees in dental facilities. The mean WTP amounts for tooth extraction were Tshs 5,448 (2.5 US$) and Tshs 6,188 (2.8 US$) for anterior and posterior teeth respectively. WTP amounts were shown to vary by age, income, outpatient status and previous experience with the dental services. Belonging in youngest age group (18-24 years) and having a high-income level was associated with increased odds for high WTP valuations irrespective of tooth and treatment types. CONCLUSIONS: WTP reveals a preference for tooth filling rather than extraction services in this population. More studies are needed to address the discrepancy between the stated preferences and utilization patterns for dental services.

Economic evaluation of antibiotic therapy versus appendicectomy for the treatment of uncomplicated acute appendicitis from the APPAC randomized clinical trial.

BACKGROUND: An increasing amount of evidence supports antibiotic therapy for treating uncomplicated acute appendicitis. The objective of this study was to compare the costs of antibiotics alone versus appendicectomy in treating uncomplicated acute appendicitis within the randomized controlled APPAC (APPendicitis ACuta) trial. METHODS: The APPAC multicentre, non-inferiority RCT was conducted on patients with CT-confirmed uncomplicated acute appendicitis. Patients were assigned randomly to appendicectomy or antibiotic treatment. All costs were recorded, whether generated by the initial visit and subsequent treatment or possible recurrent appendicitis during the 1-year follow-up. The cost estimates were based on cost levels for the year 2012. RESULTS: Some 273 patients were assigned to the appendicectomy group and 257 to antibiotic treatment. Most patients randomized to antibiotic treatment did not require appendicectomy during the 1-year follow-up. In the operative group, overall societal costs (€5989·2, 95 per cent c.i. 5787·3 to 6191·1) were 1·6 times higher (€2244·8, 1940·5 to 2549·1) than those in the antibiotic group (€3744·4, 3514·6 to 3974·2). In both groups, productivity losses represented a slightly higher proportion of overall societal costs than all treatment costs together, with diagnostics and medicines having a minor role. Those in the operative group were prescribed significantly more sick leave than those in the antibiotic group (mean(s.d.) 17·0(8·3) (95 per cent c.i. 16·0 to 18·0) versus 9·2(6·9) (8·3 to 10·0) days respectively; P < 0·001). When the age and sex of the patient as well as the hospital were controlled for simultaneously, the operative treatment generated significantly more costs in all models. CONCLUSION: Patients receiving antibiotic therapy for uncomplicated appendicitis incurred lower costs than those who had surgery.

Productivity benchmarks for operative service units.

BACKGROUND: Easily accessible reliable information is crucial for strategic and tactical decision-making on operative processes. We report development of an analysis tool and resulting metrics for benchmarking purposes at a Finnish university hospital. METHODS: The analysis tool is based on data collected in a resource management system and an in-house cost-reporting database. RESULTS: The exercise reports key metrics for four operative service units and six surgical units from 2014 and the change from year 2013. Productivity, measured as total costs per total hours, ranged from 658 to 957 €/h and utilization of the total available resource hours at the service unit level ranged from 66% to 74%. The lowest costs were in a unit running only regular working hour shifts, whereas the highest costs were in a unit operating on 24/7 basis. The tool includes additional metrics on operating room (OR) scheduling and monthly data to support more detailed analysis. CONCLUSION: This report provides the hospital management with an improved and detailed overview of its operative service units and the surgical process and related costs. The operating costs are associated with on call duties, size of operative service units, and the requirements of the surgeries. This information aids in making mid- to long range decisions on managing OR capacity.

Measuring the economic value of morning stiffness: consistency over 1 year.

OBJECTIVES: The aims of this study were to determine the within-patient variation in the duration of morning stiffness (MS) over 1 year and the corresponding monetary equivalents assigned to its changes using the willingness-to-pay (WTP) methodology. METHOD: A sample of 100 patients with rheumatoid arthritis (RA) was drawn from the register of the Hospital District of Southwest Finland. Subjects were interviewed by telephone on recruitment and 1 year later, using the same structured questionnaire. The subjects were asked to estimate in minutes the typical duration of their MS during the previous week. Sociodemographic background data and subjects' WTP for a 25, 50, 75, and 100% reduction in MS duration were requested, and years with RA diagnosis and serological data were obtained from hospital records. RESULTS: After 1 year, there was a reduction in average MS duration from 44.7 min to 39.0 min (ns); duration was reduced in 35% of patients, unchanged in 35%, and prolonged in 30%. Changes in MS duration were reflected by within-patient variation in WTP estimates. In linear regression models, change in duration of MS significantly (p < 0.03) explained the variation in change of WTP for symptom reduction. CONCLUSIONS: WTP methodology produces consistent monetary values to assess the relative values patients with RA place on reduction in duration of MS.

Psoriasis causes significant economic burden to patients.

INTRODUCTION: Psoriasis results in expenses to patients from many cost sources. Psoriasis treatments may result in considerable time and traveling costs, yet many studies fail to account for these costs. The objective of this study was to evaluate the multidimensional economic burden of psoriasis to patients. METHODS: The study was based on 232 Finnish patients with psoriasis or psoriatic arthritis visiting a tertiary level dermatological clinic during a 1-year study period between October 1, 2009 and September 30, 2010. The data were based on a patient questionnaire, clinical data from the medical records and reimbursement data from the Finnish Social Insurance Institution. Item costs were based on true costs charged from the patients and all time cost estimates were based on the Human Capital Approach method. RESULTS: 199 patients with psoriasis and 33 with psoriatic arthritis were included in the study. Total costs were higher for patients receiving traditional systemic medications or phototherapy than those not receiving such treatment. Travel costs and travel time costs accounted for more than 60% of the costs of phototherapy. Skin care at home was time consuming and thus caused significant burden to patients. The majority of the visit costs arose from hospital visits and only a small proportion were attributed to visiting primary health care providers. CONCLUSION: Visit charges and other patient co-payments were estimated to play a minor role in the total cost of psoriasis incurred by patients, while travel costs and lost time comprised the majority of the costs, which should not be omitted in future studies regarding costs of treatments.

Consistency of assessments and willingness to pay for a reduction in morning symptoms over time in patients with rheumatoid arthritis.

OBJECTIVES: To determine the variation in morning symptoms and in the corresponding monetary equivalents assigned to their reduction. METHODS: The sampled (n = 100) rheumatoid arthritis (RA) patients were interviewed twice by a trained interviewer using the same interview, 2 weeks apart. Patients assessed fatigue, pain, and severity of morning stiffness (MS) on waking up and after maximum improvement on a numeric rating scale (NRS). Patients estimated the duration of MS in minutes and reported the number of tender and swollen joints. Patients were also asked to estimate how much they would be willing to pay on a daily basis if pain, duration of MS, and severity of MS when waking up could be reduced by 25, 50, 75, and 100%. Weighted averages of the monetary assessments for symptom reduction were computed. RESULTS: On average, the NRS values at the first and second assessments were close to each other, except for fatigue and pain, which were significantly lower (p < 0.01) in the second assessment. There was limited within-patient variation, with the majority of symptom assessments within a range of ±10%. Weighted average willingness-to-pay (WTP) estimates were consistent across time points for reduction in pain and MS severity and duration. Changes in symptom assessments were reflected in the WTP estimates. CONCLUSIONS: The duration and severity of MS seemed to be more consistent over time than pain and fatigue. WTP estimates and their changes corresponded closely to changes in symptom assessments.

How much is a reduction in morning stiffness worth to patients with rheumatoid arthritis?

OBJECTIVE: The aim of this study was to determine the monetary equivalent of the emotional and functional impact of morning stiffness (MS) in patients with rheumatoid arthritis (RA), using alternative valuing methods. METHODS: Telephone interviews were conducted among 166 patients with RA to assess utility and clinical symptoms, including MS. Three standard economic methods were used: the human capital approach (HCA), marginal value of time (MVT), and willingness-to-pay (WTP). RESULTS: The monetary equivalent of the impact of MS varied with the method used (from EUR 5.74 to EUR 17.87 per patient per day) and severity of MS (5-8-fold higher in patients with severe MS compared with mild MS). Patients placed considerable value on a reduction in duration and severity of MS. Patients with MS lasting an hour or more were willing to pay EUR 21.74/day to stop the symptom and EUR 10.63/day to halve the duration. Patients with severe MS were willing to pay EUR 47.86/day to stop the symptom and EUR 21.68/day to halve the severity. CONCLUSIONS: The observed variation in the monetary equivalent of the impact of MS obtained with the three estimation methods indicates that the findings of studies using different valuing methods should not be compared directly. The study demonstrates that a reduction in MS is worth a considerable amount to patients with RA, particularly those with severe or prolonged MS. These findings suggest that clinical treatment decisions to improve patients' quality of life should also incorporate therapy that reduces MS.

Cost-benefit analysis of Helicobacter pylori screening.

BACKGROUND: Helicobacter pylori screening may markedly reduce mortality and morbidity in the decades ahead. AIMS: This study explores the costs and benefits of population-based H. pylori screening in terms of health care cost taking into account all relevant H. pylori-related diseases. MATERIAL AND METHODS: The computer-based decision analysis compared two strategies: (1) screen for H. pylori and treat those individuals who test positive, and (2) do not screen for H. pylori, and test and treat H. pylori only if related clinical symptoms appear. The model estimated the discounted H. pylori-related accumulative health care costs from screening age to death in both strategies. The baseline case estimates cost-benefit for screenees aged 15-45 years. The main outcome measure is the incremental health care cost per case in the screening compared with the no-screening alternative. The probability estimates were obtained from the Finnish Vammala H. pylori screen and treat project, including 5288 subjects in the years 1996-1998, published studies, national statistics and hospitals' internal accounts. RESULTS: The incremental cost per case was 26 US dollars in the screening compared with the no-screening alternative. It was lowest in the group aged 45 years, where H. pylori screening showed cost savings per case. CONCLUSIONS: H. pylori screening is more favourable in the older age cohorts. The estimated cost per screenee can be considered to be very acceptable if the current pathophysiological evidence on the potential effects of H. pylori eradication are confirmed in the future. However, there is uncertainty about the possible negative effect of eradicating H. pylori infection on gastro-esophageal reflux disease and esophageal adenocarcinoma. This could change the balance of benefits against risks of eradicating H. pylori infection.

Oral health indicators poorly predict coronary heart disease deaths.

Several earlier studies have suggested that development of coronary heart disease (CHD) is causally related to oral infections. The aim of this study was to investigate the association between oral health indicators and CHD deaths. Out of a nationally representative sample, 6527 men and women aged 30-69 years participated in the health examination with a dental check. Detailed oral health data included caries, periodontal and dental plaque status, presence of remaining teeth, and various types of dentures. Over a mean 12-year follow-up, persons dying of CHD were older and more often smoked, had hypertension, hypercholesterolemia, diabetes, and only a basic education compared with other persons. In univariate analyses, several oral health indicators were associated with CHD deaths. Adjustment for the established CHD risk factors reduced all these associations to statistical non-significance. The associations between oral health indicators and CHD are mostly explained by confounding factors, particularly those relating to health behavior.

Perceived competition in private dental practice in Finland.

A questionnaire study was conducted among 350 private dentists in Finland to investigate their perception of competition and how this associated with practice characteristics. The questionnaire comprised 46 questions dealing with perceptions of competition, marketing, and collegiality, respondents' personal and practice characteristics, including age, sex, area of main practice location, weekly hours in private practice, functioning in solo or in joint practice, cooperation with other dentists, and whether practicing in more than one location. The majority of these private dental practitioners perceived much competition between themselves. Almost all (96%) of those feeling much competition today expected it to be more intense after 5 years, compared to 60% of those not perceiving much competition today (P < 0.001). Private practitioners perceiving much competition also felt it from public health centers significantly (P < 0.001) more often (46%) than others (24%). Logistic regression models revealed that those with a practice in more than one location were over 7 times more likely not to perceive competition. Those practicing outside metropolitan Helsinki area had 3.6 times the odds of not perceiving competition, and for women overall the odds ratio was 2.5. Increasing competition in private practice is a widely felt concern, and it may diminish the willingness of new graduates to attempt penetration of the market and establish their clinics.

Incremental cost-effectiveness of double-reading mammograms.

BACKGROUND: Double reading is a widely used criterion standard in breast cancer screening despite a lack of evidence of the cost-effectiveness of the second reading. This study evaluates the incremental cost-effectiveness of such a strategy. DESIGN: Cost-effectiveness analysis: Nationwide population-based semi-annual screening program for women aged 50-59 in Finland. Participation rate was 91%. All mammograms (95,423) performed during 1990-1995 in three screening centers of the Finnish Cancer Society were read by two radiologists with gradings recorded. The effectiveness of the double reading was the difference in cancers detected in the double compared to that of the single reading. Incremental costs of the double reading for the health care and non-health care and the time costs were estimated. The main outcome measure was the incremental cost per additional cancer found as a result of the double-reading strategy. RESULTS: The total number of cancers detected with the double and single reading were 290 and 261, respectively. A significantly higher ratio of carcinoma in situ was the causative pathology in cancers detected only by the second reader. The cost per cancer detected with a single reading was US$ 18,340. The incremental cost of any additional cancer found was US$ 25,523, that is, a 39% higher cost per additional cancer found by double reading. CONCLUSIONS: The additional cost per cancer detected by double reading is not drastically higher than with single reading. However, the additional cost per life year saved may be much higher.

The cost-effectiveness of nationwide breast carcinoma screening in Finland, 1987-1992.

BACKGROUND: The aim of this study was to evaluate the cost-effectiveness, from a societal perspective, of the Finnish nationwide breast carcinoma screening program. METHODS: The effects were measured in life-years saved from 1987 to 2020, using data from the nationwide program to the end of 1992. A total of 90,000 women ages 50-59 were invited for screening during the years 1987-89. The total number of participants screened was 76,000. The screening interval was 24 months, with follow-up to the end of 1992. From the beginning of 1993, the estimation model used parameters based on published studies and national cancer statistics. Data on health care and non-health care costs and time costs were obtained from internal accounts of screening units, published studies, national statistics, health market sources, and a questionnaire completed by a sample of 1400 screening attendees. The discount rate, the annual rate of time preference over future costs and life-years saved, was 3%. The main outcome measure was the cost per life-year saved. RESULTS: The estimated number of life-years of life saved was 578, of which 8% occurred 1987-1992. The estimated life-years saved per 1000 screenings was 3.2. The total costs were $11 million in U.S. dollars, i.e., $14.3 million per 100,000 participants. CONCLUSIONS: The cost of breast carcinoma mammographic screening per life-year saved was $18,955 in the base case, ranging from $15,502 to $40,308 according to the different models used in analysis.

Satisfaction with dental care among elderly Finnish men.

To study satisfaction with dental care among elderly Finnish men and to estimate the role of different factors affecting it, a questionnaire was sent to a systematic sample of 2043 elderly Finnish men (mean age 73 years). Acceptably filled-out questionnaires were returned by 1561, a participation rate of 76.4%. The questionnaire included 44 questions concerning dental and denture services and a modified 14-item Dental Satisfaction Questionnaire. The subjects were asked to express how strongly they agreed or disagreed with each of the 14 statements. These were later transformed and recoded to indicate level of satisfaction from +2 (very satisfied) to -2 (very dissatisfied). Overall satisfaction was estimated by summing up all the 14 scores. Dentate subjects were significantly (P<0.01) more satisfied than the edentulous. Subjects were least satisfied with dental care fees and most satisfied with accessibility and availability of services. Dentate subjects viewed almost all 14 items significantly more favorably than did the edentulous. Economics was seen to have a strong influence on dissatisfaction with dental care fees, which was related to income level. Maintaining the remaining dentition and supporting the dentition with fixed or removable dentures seem to be the means to increase satisfaction among the dentate. The benefits of belonging to a clinic's recall system should be explained thoroughly to the elderly.

A 5-year retrospective analysis of employer-provided dental care for Finnish male industrial workers.

The treatment-mix, treatment time, and dental status of 268 male industrial workers entitled to employer-provided dental care were studied. The data were collected from treatment records of the covered workers over the 5-year period 1989-93. Treatment time was based on clinical treatment time recorded per patient visit, and the treatment procedure codes were reclassified into a treatment-mix according to American Dental Association categories, with a modification combining endodontics and restorative treatment. The mean number of check-ups followed by prescribed treatment (treatment courses) during the 5 years was 3.7 among those who had entered the in-house dental care program prior to the monitored period (old attenders). Their treatment time was stable, 57-63 min per year, while the first-year mean treatment time (170 min) of those who had entered the program during the study period (new attenders) was significantly higher (P < 0.01) than the 5-year mean of the old attenders (61 min). Over the first 2 years, the treatment-mix of the new attenders showed a rise in diagnostic and preventive procedures from one-third to about one-half of all procedures, as it was for the old attenders. The new attenders' mean number of carious teeth (2.7), registered at the initial check-up visit, paralleled the mean recently demonstrated in the similar non-covered population. It was significantly higher than the 5-year mean of the old attenders (0.5) (P < 0.001), but declined to the same level after the first year of treatment. It was concluded that the studied program seemed to contribute to a stabilization of treatment-mix, and to the establishment of a shorter annual treatment time within the first 2 years of treatment.

Dental knowledge, attitudes towards oral health care and utilization of dental services among male industrial workers with or without an employer-provided dental benefit scheme.

In industrialized countries various dental benefit schemes have been implemented to improve the utilization of dental services, though few studies have demonstrated that effect. Prior to a comprehensive clinical study in southern Finland, a postal questionnaire survey of male industrial workers (age 38-65 yrs) was conducted to investigate knowledge and attitudes concerning oral health care and whether access to an employer-provided dental benefit scheme was associated with the utilization of dental services. The response rate was 81% (n = 325) in the subsidized group and 69% (n = 174) in the control group. In both groups, 60% of the subjects had had their last dental visit within a year but 91% of the subsidized workers compared to 79% of the controls had visited a dentist in the past two years (P < 0.001). The subjects had similar attitudes towards the importance of regular dental care and its implications for dental and general health. Subsidization explained the disparity in the current dental visiting pattern between the groups better than the possibility of using working hours for dental visits. Backward stepwise logistic regression revealed that the probability of a dental visit within the past two years was positively associated with access to an employer-provided dental benefit scheme, tooth brushing to maintain dental health, and number of teeth, and negatively associated with number of carious teeth. Our results demonstrate a positive impact of subsidization on the utilization of dental services.

Subsidized dental care improves caries status in male industrial workers.

The association between an employer-provided dental benefit scheme and dental status was studied in male industrial workers in southern Finland in 1994. A total of 325 workers (age 38-65 yrs) with access to subsidized dental care and 174 controls completed a multiple-choice questionnaire followed by clinical examinations. One or more carious teeth was registered in 19% of the subsidized group and 50% of the controls (P < 0.001). For subjects with retained roots the proportions were 2% and 15%, respectively (P < 0.001). Among those with caries the mean number of carious teeth was 2.1 (SD 2.0) in the subsidized group, and 3.2 (SD 3.8) in the control group (P < 0.05). The groups did not differ significantly in numbers of teeth or filled teeth. The probability of having one or more carious teeth was negatively associated with access to subsidized dental care, with a recall or check-up as the reason for the last dental visit, and with having had the last dental visit within the past two years. The results showed that the dental benefit scheme resulted in less untreated caries.

Oral mucosal changes and associated factors among male industrial workers with or without access to subsidized dental care.

Oral mucosal changes and associated factors were studied among male industrial workers in southern Finland. Two groups, with or without access to an employer-provided dental benefit scheme, were compared. A multiple-choice questionnaire followed by clinical examinations was completed by 325 (81%) subsidized workers and 174 (69%) controls. In both groups 52% of the subjects had some oral mucosal change, and there were no significant differences between the groups in the location distribution of the changes. Smoking was significantly associated with redness of the oral mucosa (p < 0.001), coating (p < 0.001), and leukoplakia (p < 0.01), whereas denture wearing was associated with ulcers (p < 0.05), hyperplasia (p < 0.001), and redness (p < 0.001). Among denture wearers non-acceptable dentures were significantly associated with hyperplasia (p < 0.001). The subsidized group had better dentures, although this did not significantly benefit their oral mucosal status.

Periodontal status among male industrial workers in southern Finland with or without access to subsidized dental care.

The association between subsidized dental care and periodontal status was studied in male industrial workers in southern Finland in 1994. Clinical examinations and a multiple-choice questionnaire were completed for 325 workers (age, 38-65 years) with access to subsidized dental care and 174 controls without access. The CPITN scores based on full-mouth recordings were analyzed, using both the individual and sextant as units of analysis. Overall, 6% of the subsidized group and 2% of the control group had no periodontal treatment need (p < 0.05). Deep pockets > or = 6 mm were found in 5% of the subsidized workers and 11% of the controls (p < 0.05). In the logistic regression analyses the probability of calculus was negatively associated with access to subsidized dental care. Smoking was the strongest independent factor affecting periodontal status. Our findings show a positive relationship between access to subsidized dental care and periodontal status.

Cost-effectiveness of one-stage ultrasound screening in pregnancy: a report from the Helsinki ultrasound trial.

The objective of this study was to evaluate, in a controlled clinical trial, the costs of standardized one-stage ultrasound screening in pregnancy in relation to the reduction in perinatal mortality. A trial population of 9310 pregnant women was randomly allocated to ultrasound screening or a control group. Two obstetric hospitals and 64 recruiting antenatal health centers were involved. The costs included actually realized costs, i.e. positive costs, and gains, i.e. negative costs, resulting from lower health-care use. Cost-accounting data were obtained by a questionnaire to all attenders and measurements at the screening, and later complemented by a questionnaire to a random sample of 534 screened women. Internal accounting and other hospital data, national statistics and health-market sources were also used. The actually realized cost of each avoided perinatal death was FIM 84 378 ($21,938), while the net overall estimate combining all positive and negative costs showed a cost saving of FIM 65 680 ($17,077). The total positive unit cost of ultrasound screening was FIM 393 ($102). Longer ultrasound examination time and more numerous advanced examinations were rewarded by clearly fewer perinatal deaths and a better cost-effectiveness ratio. One-stage second-trimester ultrasound screening is cost-effective when all significant costs and effects are taken into account.