A cost-effectiveness analysis of community water fluoridation for schoolchildren.

BACKGROUND: Community water fluoridation (CWF), the controlled addition of fluoride to the water supply for the prevention of dental caries (tooth decay), is considered a safe and effective public health intervention. The Republic of Ireland (Ireland) is the only country in Europe with a legislative mandate for the fluoridation of the public water supply, a key component of its oral health policy. However, more recently, there has been an increase in public concern around the relevance of the intervention given the current environment of multiple fluoride sources and a reported increase in the prevalence of enamel fluorosis. The aim of this economic analysis is to provide evidence to inform policy decisions on whether the continued public investment in community water fluoridation remains justified under these altered circumstances. METHODS: Following traditional methods of economic evaluation and using epidemiological data from a representative sample of 5-, 8-, and 12-year-old schoolchildren, this cost-effectiveness analysis, conducted from the health-payer perspective, compared the incremental costs and consequences associated with the CWF intervention to no intervention for schoolchildren living in Ireland in 2017. A probabilistic model was developed to simulate the potential lifetime treatment savings associated with the schoolchildren's exposure to the intervention for one year. RESULTS: In 2017, approximately 71% of people living in Ireland had access to a publicly provided fluoridated water supply at an average per capita cost to the state of €2.15. The total cost of CWF provision to 5-, 8-, and 12-year-old schoolchildren (n = 148,910) was estimated at €320,664, and the incremental cost per decayed, missing, or filled tooth (d3vcmft/D3vcMFT) prevented was calculated at €14.09. The potential annual lifetime treatment savings associated with caries prevented for this cohort was estimated at €2.95 million. When the potential treatment savings were included in the analysis, the incremental cost per d3vcmft/D3vcMFT prevented was -€115.67, representing a cost-saving to the health-payer and a positive return on investment. The results of the analysis were robust to both deterministic and probability sensitivity analyses. CONCLUSION: Despite current access to numerous fluoride sources and a reported increase in the prevalence of enamel fluorosis, CWF remains a cost-effective public health intervention for Irish schoolchildren.

Planning the oral health workforce: Time for innovation.

The levels and types of oral health problems occurring in populations change over time, while advances in technology change the way oral health problems are addressed and the ways care is delivered. These rapid changes have major implications for the size and mix of the oral health workforce, yet the methods used to plan the oral health workforce have remained rigid and isolated from planning of oral healthcare services and healthcare expenditures. In this paper, we argue that the innovation culture that has driven major developments in content and delivery of oral health care must also be applied to planning the oral health workforce if we are to develop 'fit for purpose' healthcare systems that meet the needs of populations in the 21st century. An innovative framework for workforce planning is presented focussed on responding to changes in population needs, service developments for meeting those needs and optimal models of care delivery.

Needs-based planning for the oral health workforce - development and application of a simulation model.

BACKGROUND: The World Health Organization's global strategy on human resources for health includes an objective to align investment in human resources for health with the current and future needs of the population. Although oral health is a key indicator of overall health and wellbeing, and oral diseases are the most common noncommunicable diseases affecting half the world's population, oral health workforce planning efforts have been limited to simplistic target dentist-population or constant services-population ratios which do not account for levels of and changes in population need. Against this backdrop, our aim was to develop and operationalise an oral health needs-based workforce planning simulation tool. METHODS: Using a conceptual framework put forward in the literature, we aimed to build the model in Microsoft Excel and apply it in a hypothetical context to demonstrate its operability. The model incorporates a provider supply component and a provider requirement component, enabling a comparison of the current and future supply of and requirement for oral health workers. Publicly available data, including the Special Eurobarometer 330 Oral Health Survey, were used to populate the model. Assumptions were made where data were not publicly available and key assumptions were tested in scenario analyses. RESULTS: We have systematically developed a needs-based workforce planning model for the oral health workforce and applied the model in a hypothetical context over a 30-year time span. In the 2017 baseline scenario, the model produced a full-time equivalent (FTE) provider requirement figure of 899 dentists compared with an FTE provider supply figure of 1985. In the scenario analyses, the FTE provider requirement figure ranged from 1123 to 1629 illustrating the extent of the impact of changing parameter values. CONCLUSIONS: In response to policy makers' recognition of the pressing need to better plan human resources for health and the scarcity of work in this area for dentistry, we have demonstrated the feasibility of producing a workable, practical and useful needs-based workforce planning simulation tool for the oral health workforce. In doing so, we have highlighted the challenges faced in accessing timely and relevant data needed to populate such models and ensure the reliability of model outputs.

Dementia in older people admitted to hospital: An analysis of length of stay and associated costs.

OBJECTIVES: Patients with dementia in the acute setting are generally considered to impose higher costs on the health system compared to those without the disease largely due to longer length of stay (LOS). Many studies exploring the economic impact of the disease extrapolate estimates based on the costs of patients diagnosed using routinely collected hospital discharge data only. However, much dementia is undiagnosed, and therefore in limiting the analysis to this cohort, we believe that LOS and the associated costs of dementia may be overestimated. We examined LOS and associated costs in a cohort of patients specifically screened for dementia in the hospital setting. METHODS: Using primary data collected from a prospective observational study of patients aged ≥70 years, we conducted a comparative analysis of LOS and associated hospital costs for patients with and without a diagnosis of dementia. RESULTS: There was no significant difference in overall length of stay and total costs between those with (µ = 9.9 days, µ = € 8246) and without (µ = 8.25 days, µ = € 6855) dementia. Categorical data analysis of LOS and costs between the two groups provided mixed results. CONCLUSIONS: The results challenge the basis for estimating the costs of dementia in the acute setting using LOS data from only those patients with a formal dementia diagnosis identified by routinely collected hospital discharge data. Accurate disease prevalence data, encompassing all stages of disease severity, are required to enable an estimation of the true costs of dementia in the acute setting based on LOS.

The non-drug costs associated with the administration of an intravenous biologic treatment in the hospital setting.

BACKGROUND: In Ireland, over 20,000 people are affected by inflammatory bowel disease (IBD). The licenced biologic therapies to treat moderate to severe IBD are reported to have similar effectiveness levels but differ in their methods of delivery. Certain therapies are administered by intravenous (IV) infusion in the hospital setting, others are delivered by subcutaneous injection in the community. AIM: To determine the non-drug costs involved in administering an IV biologic infusion in the hospital setting. METHODS: This time-and-motion study was conducted at an Infusion Day Unit (IDU) in an Irish teaching hospital. The sequence and duration of each patient's use of resources was recorded and costed. Bootstrap methods were applied to ensure that robust estimates of the accuracy of the non-parametric population statistics were reliably estimated. RESULTS: The mean time the patient spent at the IDU was 143.78 mins with a mean treatment time of 129.81 min. The main driver of patient time was the drug infusion time (39%), followed by the monitoring period (25%). The mean cost was €224.54 per treatment. Nurse time was the main expenditure driver (37%), followed by laboratory costs (27%) and other healthcare professional's costs (14%). CONCLUSIONS: The study confirms that the non-drug costs associated with the delivery of an IV biologic in the hospital setting are non-trivial. Given the current budgetary climate of health systems, the compounding prevalence of IBD and the expected increase in patient numbers, it is imperative that physicians also consider the opportunity costs associated with the method of treatment delivery.

A retrospective investigation of the oral health records of a cohort of preschool children who received extractions under general anaesthesia including cost analysis of treatment.

Internationally, a considerable proportion of children aged five years and younger require extraction of teeth due to dental caries and frequently dental general anaesthesia (DGA) is the treatment of choice. AIMS: To investigate the records of a cohort of preschool children (aged five years and younger) referred to the public dental service provided at Cork University Hospital (CUH), Cork, Ireland, for extractions under DGA between the years 2000 and 2002. To determine the characteristics of the sample: disadvantage; the presence of a significant medical history; and, fluoride status. To establish the pattern of appointments and care, before, during and after DGA, and the pattern of dental treatment required up to sixth class (aged 11 to 12 years). METHODS: A retrospective review of dental records of a cohort of preschool-aged children referred for DGA in CUH during the years 2000-2002 was completed. Demographic and clinical data were collated and analysed using Statistical Packages for Social Sciences (SPSS). Costs were provided by CUH and the Health Service Executive (HSE). Data on costs relating to preventive programmes were obtained from information presented in the Irish Oral Health Services Guideline Initiative 2009. RESULTS: A total of 347 children were included with a median age of.fQur years and a range of one to five years. Children with a disadvantage were more likely to require extractions under DGA than their- counterparts (50%, n=175). In total, 73% (n=253)~ of patients had a fluoridated water supply and 91% (n=316) had no adverse medical history. For 88% (n=306), their first dental visit was an emergency appointment. The primary indication for DGA was treatment of dental caries. A recall appointment was provided for 18% (n=63). One-quarter (n=86) required an extraction, antibiotic or referral for a second DGA at their first visit following DGA. In first class, referral for a second DGA or extraction under local anaesthetic (LA) was required for 23% (n=79) of patients. Over 60% (n=21 1) required either an extraction or a restoration in third class. In excess of 20% (n=69) of patients did not attend the sixth class dental inspection, the final assessment appointment in the public services. CONCLUSIONS: A considerable number of preschool children require extractions under DGA due to dental caries. The results of this study indicate that such children progress to adolescence with poor oral health, as evidenced by the need for further restorations, extractions and repeat DGA. The average cost of DGA was E819 per child. This figure has been shown to be as much as eight times the cost of a preventive/oral health promotion prograrnme operating within a similar cohort. An integrated preventive programme targeting preschool-aged children should be considered in attempting to manage the hicih levels of dental caries within this age group.

Structured Pharmacist Review of Medication in Older Hospitalised Patients: A Cost-Effectiveness Analysis.

BACKGROUND: A recent cluster randomised controlled trial (RCT) conducted in an Irish hospital evaluating a structured pharmacist review of medication (SPRM), supported by computerised clinical decision support software (CDSS), demonstrated positive outcomes in terms of reduction of adverse drug reactions (ADR). OBJECTIVE: The aim of this study was to examine the cost effectiveness of pharmacists applying an SPRM in conjunction with CDSS to older hospitalised patients compared with usual pharmaceutical care. METHOD: Cost-effectiveness analysis alongside a cluster RCT. The trial was conducted in a tertiary hospital in the south of Ireland. Patients in the intervention arm (n = 361) received a multifactorial intervention consisting of medicines reconciliation, deployment of CDSS and generation of a pharmaceutical care plan. Patients in the control arm (n = 376) received usual care from the hospital pharmacy team. Incremental cost effectiveness was examined in terms of costs to the healthcare system and an outcome measure of ADRs during an inpatient hospital stay. Uncertainty in the analysis was explored using a cost-effectiveness acceptability curve (CEAC). RESULTS: On average, the intervention arm was the dominant strategy in terms of cost effectiveness. Compared with usual care (control), the intervention was associated with a decrease of €807 [95% confidence interval (CI) -3443 to 1829; p = 0.548) in mean healthcare cost, and a decrease in the mean number of ADR events per patient of -0.064 (95% CI -0.135 to 0.008; p = 0.081). The probability of the intervention being cost effective at respective threshold values of €0, €250, €500, €750, €1000 and €5000 was 0.707, 0.713, 0.716, 0.718, 0.722 and 0.784, respectively. CONCLUSIONS: Based on the evidence presented, SPRM/CDSS is likely to be determined to be cost effective compared with usual pharmaceutical care. However, neither incremental costs nor effects demonstrated a statistically significant difference, therefore the results of this single-site study should be interpreted with caution.

Copayments for prescription medicines on a public health insurance scheme in Ireland.

PURPOSE: We assessed the impact of the introduction of a €0.50 prescription copayment, and its increase to €1.50, on adherence to essential and less-essential medicines in a publicly insured population in Ireland. METHODS: We used a pre-post longitudinal repeated measures design. We included new users of essential medicines: blood pressure lowering, lipid lowering and oral diabetic agents, thyroid hormone, anti-depressants, and less-essential medicines: non-steroidal anti-inflammatory drugs (NSAIDs), Proton Pump Inhibitors/H2 antagonists (PPIs/H2 ), and anxiolytics/hypnotics. The outcome was change in adherence, measured using Proportion of Days Covered. We used segmented regression with generalised estimating equations to allow for repeated measurements. RESULTS: Sample sizes ranged from 7145 (thyroid hormone users) to 136 111 (NSAID users). The €0.50 copayment was associated with reductions in adherence ranging from -2.1%[95% CI, -2.8 to -1.5] (thyroid hormone) to -8.3%[95% CI, -8.7 to -7.9] (anti-depressants) for essential medicines and reductions in adherence of -2%[95% CI, -2.3 to -1.7] (anxiolytics/hypnotics) to -9.5%[95% CI, -9.8 to -9.1] (PPIs/H2 ) for less-essential medicines. The €1.50 copayment generally resulted in smaller reductions in adherence to essential medicines. Anti-depressant medications were the exception with a decrease of -10.0% [95% CI, -10.4 to -9.6] after the copayment increase. Larger decreases in adherence were seen for most less-essential medicines; the largest was for PPIs/H2 at -13.5% [95% CI, -13.9 to -13.2] after the €1.50 copayment. CONCLUSION: Both copayments had a greater impact on adherence to less-essential medicines than essential medicines. The major exception was for anti-depressant medicines. Further research is required to explore heterogeneity across different socio-economic strata and to elicit the impact on clinical outcomes. Copyright © 2015 John Wiley & Sons, Ltd.

The implications of regional and national demographic projections for future GMS costs in Ireland through to 2026.

BACKGROUND: As the health services in Ireland have become more resource-constrained, pressure has increased to reduce public spending on community drug schemes such as General Medical Services (GMS) drug prescribing and to understand current and future trends in prescribing. The GMS scheme covers approximately 37% of the Irish population in 2011 and entitles them, inter alia, to free prescription drugs and appliances. This paper projects the effects of future changes in population, coverage, claims rates and average claims cost on GMS costs in Ireland. METHODS: Data on GMS coverage, claims rates and average cost per claim are drawn from the Primary Care Reimbursement Service (PCRS) and combined with Central Statistics Office (CSO) (Regional and National Population Projections through to 2026). A Monte Carlo Model is used to simulate the effects of demographic change (by region, age, gender, coverage, claims rates and average claims cost) will have on GMS prescribing costs in 2016, 2021 and 2026 under different scenarios. RESULTS: The Population of Ireland is projected to grow by 32% between 2007 and 2026 and by 96% for the over 70s. The Eastern region is estimated to grow by 3% over the lifetime of the projections at the expense of most other regions. The Monte Carlo simulations project that females will be a bigger driver of GMS costs than males. Midlands region will be the most expensive of the eight old health board regions. Those aged 70 and over and children under 11 will be significant drivers of GMS costs with the impending demographic changes. Overall GMS medicines costs are projected to rise to €1.9bn by 2026. CONCLUSIONS: Ireland's population will experience rapid growth over the next decade. Population growth coupled with an aging population will result in an increase in coverage rates, thus the projected increase in overall prescribing costs. Our projections and simulations map the likely evolution of GMS cost, given existing policies and demographic trends. These costs can be contained by government policy initiatives.

Cost-outcome description of clinical pharmacist interventions in a university teaching hospital.

BACKGROUND: Pharmacist interventions are one of the pivotal parts of a clinical pharmacy service within a hospital. This study estimates the cost avoidance generated by pharmacist interventions due to the prevention of adverse drug events (ADE). The types of interventions identified are also analysed. METHODS: Interventions recorded by a team of hospital pharmacists over a one year time period were included in the study. Interventions were assigned a rating score, determined by the probability that an ADE would have occurred in the absence of an intervention. These scores were then used to calculate cost avoidance. Net cost benefit and cost benefit ratio were the primary outcomes. Categories of interventions were also analysed. RESULTS: A total cost avoidance of €708,221 was generated. Input costs were calculated at €81,942. This resulted in a net cost benefit of €626,279 and a cost benefit ratio of 8.64: 1. The most common type of intervention was the identification of medication omissions, followed by dosage adjustments and requests to review therapies. CONCLUSION: This study provides further evidence that pharmacist interventions provide substantial cost avoidance to the healthcare payer. There is a serious issue of patient's regular medication being omitted on transfer to an inpatient setting in Irish hospitals.

Cost-effectiveness of tooth replacement strategies for partially dentate elderly: a randomized controlled clinical trial.

OBJECTIVE: To conduct a cost-effectiveness analysis comparing two different tooth replacement strategies for partially dentate older patients, namely partial removable dental prostheses (RDP) and functionally orientated treatment based on the shortened dental arch concept (SDA). METHODS: Ninety-two partially dentate older patients completed a randomized controlled clinical trial. Patients were randomly allocated to two treatment groups: the RDP group and the SDA group. Treatment effect was measured using impact on oral health-related quality of life (OHrQOL), and the costs involved in providing and maintaining care were recorded for all patients. Patients were followed for 12 months after treatment intervention. All treatment was provided by a single operator. RESULTS: The total cost of achieving the minimally important clinical difference (MID) in OHrQOL for an average patient in the RDP group was €464.64. For the SDA group, the cost of achieving the MID for an average patient was €252.00. The cost-effectiveness ratio was therefore 1:1.84 in favour of SDA treatment. CONCLUSION: With an increasingly ageing population, many patients will continue to benefit from removable prostheses to replace their missing natural teeth. From a purely economic standpoint, the results from this analysis suggest that the treatment of partially dentate older adults should be focused on functionally orientated treatment because it is simply more cost-effective.

Cost-effectiveness of ART restorations in elderly adults: a randomized clinical trial.

BACKGROUND: As the world population ages, the requirement for cost-effective methods of treating chronic disease conditions increases. In terms of oral health, there is a rapidly increasing number of dentate elderly with a high burden of maintenance. Population surveys indicate that older individuals are keeping their teeth for longer and are a higher caries risk group. Atraumatic Restorative Treatment (ART) could be suitable for patients in nursing homes or house-bound elderly, but very little research has been done on its use in adults. OBJECTIVES: To compare the cost-effectiveness of ART and a conventional technique (CT) for restoring carious lesions as part of a preventive and restorative programme for older adults. METHODS: In this randomized clinical trial, 82 patients with carious lesions were randomly allocated to receive either ART or conventional restorations. Treatment costs were measured based on treatment time, materials and labour. For the ART group, the cost of care provided by a dentist was also compared to the cost of having a hygienist to provide treatment. Effectiveness was measured using percentage of restorations that survived after a year. RESULTS: Eighty-two patients received 260 restorations, that is, 128 ART and 132 conventional restorations. 91.1% of the restorations were on one surface only. After a year, 252 restorations were assessed in 80 patients. The average cost for ART and conventional restorations was €16.86 and €28.71 respectively; the restoration survival percentages were 91.1% and 97.7%, respectively. This resulted in a cost-effectiveness ratio of 0.18 (ART) and 0.29 (CT). When the cost of a hygienist to provide ART was inserted in the analysis, the resulting ratio was 0.14. CONCLUSIONS: Atraumatic restorative treatment was found to be a more cost-effective alternative to treat older adults after 1 year, compared to conventional restorations, especially in out of surgery facilities and using alternative workforce such as hygienists. Atraumatic restorative treatment can be a useful tool to provide dental care for frail and fearful individuals who might not access dental treatment routinely.

A preliminary report of the cost-effectiveness of tooth replacement strategies for partially dentate elders.

OBJECTIVE: To compare the cost-effectiveness of conventional treatment using partial dentures with functionally orientated treatment to replace missing teeth for partially dentate elders using a randomised controlled clinical trial. BACKGROUND: In many countries, including the Republic of Ireland, the only publically funded treatment option offered to partially dentate older patients is a removable partial denture. However, evidence suggests that these removable prostheses are unpopular with patients and can potentially increase the risk of further dental disease and subsequent tooth loss. MATERIALS AND METHODS: Fourty-four partially dentate patients aged 65 years and older were recruited. Patients were randomly assigned to the two treatment arms of the study. The conventional treatment group received removable partial dentures to replace all missing natural teeth. The functionally orientated group was restored to a Shortened Dental Arch (SDA) of 10 occluding contacts using resin-bonded bridgework (RBB). The costs associated with each treatment were recorded. Effectiveness was measured in terms of the impact on oral health-related quality of life (OHRQoL) using OHIP-14. RESULTS: Both groups reported improvements in OHRQoL 1 month after completion of treatment. The conventional treatment group required 8.3 clinic visits as compared to 4.4 visits for the functionally orientated group. The mean total treatment time was 183 min 19 s for the conventional group vs. 124 min 8 s for the functionally orientated group. The average cost of treatment for the conventional group was 487.74 Euros compared to 356.20 Euros for the functional group. CONCLUSIONS: Functionally orientated treatment was more cost-effective than conventional treatment in terms of treatment effect and opportunity costs to the patients' time.

Comparing epidemiologically estimated treatment need with treatment provided in two dental schemes in Ireland.

BACKGROUND: Valid estimation of dental treatment needed at population level is important for service planning. In many instances, planning is informed by survey data, which provide epidemiologically estimated need from the dental fieldworkers' perspective. The aim of this paper is to determine the validity of this type of information for planning. A comparison of normative (epidemiologically estimated) need for selected treatments, as measured on a randomly-selected representative sample, is compared with treatment actually provided in the population from which the sample was drawn. METHODS: This paper compares dental treatment need-estimates, from a national survey, with treatment provided within two choice-of-dentist schemes: Scheme 1, a co-payment scheme for employed adults, and Scheme 2, a 'free' service for less-well-off adults. Epidemiologically estimated need for extractions, restorations, advanced restorations and denture treatments was recorded for a nationally representative sample in 2000/02. Treatments provided to employed and less-well-off adults were retrieved from the claims databases for both schemes. We used the chi-square test to compare proportions, and the student's t-test to compare means between the survey and claims databases. RESULTS: Among employed adults, the proportion of 35-44-year-olds whose teeth had restorations was greater than estimated as needed in the survey (55.7% vs. 36.7%;p <0.0001). Mean number of teeth extracted was less than estimated as needed among 35-44 and 65+ year-olds. Among less-well-off adults, the proportion of 16-24-year-olds who had teeth extracted was greater than estimated as needed in the survey (27.4% vs. 7.9%;p <0.0001). Mean number of restorations provided was greater than estimated as needed in the survey for 16-24-year-olds (3.0 vs. 0.9; p <0.0001) and 35-44-year-olds (2.7 vs. 1.4;p <0.01). CONCLUSIONS: Significant differences were found between epidemiologically estimated need and treatment provided for selected treatments, which may be accounted for by measurement differences. The gap between epidemiologically estimated need and treatment provided seems to be greatest for less-well-off adults.

Gerodontology--how big is the challenge in Ireland?

Population trends suggest that the Irish population is ageing, and that this population will have substantial treatment needs. These patients will be better informed than previous generations, and will demand treatment aimed at preserving a natural dentition. This will impact upon delivery of oral healthcare and manpower planning needs to consider how to address the increased demand for dental care. Poor oral health is associated with systemic health problems, including cardiovascular disease, respiratory disease and diabetes mellitus. It also has a negative impact upon quality of life, and the World Health Organisation has encouraged public healthcare administrators and decision makers to design effective and affordable strategies for better oral health and quality of life of older adults, which, in turn, are integrated into general health management programmes. Treatment concepts such as minimally invasive dentistry and the shortened dental arch concept are discussed in the context of these demographic changes and recommendations.