Health economic analyses of domiciliary dental care and care at fixed clinics for elderly nursing home residents in Sweden.

OBJECTIVES: Dental care for elderly nursing home residents is traditionally provided at fixed dental clinics, but domiciliary dental care is an emerging alternative. Longer life expectancy accompanied with increased morbidity, and hospitalisation or dependence on the care of others will contribute to a risk for rapid deterioration of oral health so alternative methods for delivering oral health care to vulnerable individuals for whom access to fixed dental clinics is an obstacle should be considered. The aim was to analyse health economic consequences of domiciliary dental care for elderly nursing home residents in Sweden, compared to dentistry at a fixed clinic. METHODS: A review of relevant literature was undertaken complemented by interviews with nursing home staff, officials at county councils, and academic experts in geriatric dentistry. Domiciliary dental care and fixed clinic care were compared in cost analyses and cost-effectiveness analyses. RESULTS: The mean societal cost of domiciliary dental care for elderly nursing home residents was lower than dental care at a fixed clinic, and it was also considered cost-effective. Lower cost of dental care at a fixed dental clinic was only achieved in a scenario where dental care could not be completed in a domiciliary setting. CONCLUSIONS: Domiciliary dental care for elderly nursing home residents has a lower societal cost and is cost-effective compared to dental care at fixed clinics. To meet current and predicted need for oral health care in the ageing population alternative methods to deliver dental care should be available.

Value for money: economic evaluation of two different caries prevention programmes compared with standard care in a randomized controlled trial.

A cost-effectiveness analysis was conducted during a 3-year randomized controlled clinical trial in a general dental practice in the Netherlands in which 230 6-year-old children (± 3 months) were assigned to either regular dental care, an increased professional fluoride application (IPFA) programme or a non-operative caries treatment and prevention (NOCTP) programme. Information on resource use during the 3-year period was documented by the dental nurse at every patient visit, such as treatment time, travel time and travel distance. Caries increment scores (at D3MFS level) were used to assess effectiveness. Cost calculations were performed using bottom-up micro-costing. Incremental cost-effectiveness ratios (ICERs) were expressed as additional average costs per prevented DMFS. The ICERs compared with regular dental care from a health care system perspective and societal perspective were, respectively, EUR 269 and EUR 1,369 per prevented DMFS in the IPFA programme, and EUR 30 and EUR 100 in the NOCTP programme. The largest investments for the NOCTP group were made in the first year of the study; they decreased in the second and equalled the costs of control group in third year of the study. From both medical and economic points of view, the NOCTP strategy may be considered the preferred strategy for caries prevention.

Cost analysis of periodontitis management in public sector specialist dental clinics.

BACKGROUND: The objective of this paper is to quantify the cost of periodontitis management at public sector specialist periodontal clinic settings and analyse the distribution of cost components. METHODS: Five specialist periodontal clinics in the Ministry of Health represented the public sector in providing clinical and cost data for this study. Newly-diagnosed periodontitis patients (N = 165) were recruited and followed up for one year of specialist periodontal care. Direct and indirect costs from the societal viewpoint were included in the cost analysis. They were measured in 2012 Ringgit Malaysia (MYR) and estimated from the societal perspective using activity-based and step-down costing methods, and substantiated by clinical pathways. Cost of dental equipment, consumables and labour (average treatment time) for each procedure was measured using activity-based costing method. Meanwhile, unit cost calculations for clinic administration, utilities and maintenance used step-down approach. Patient expenditures and absence from work were recorded via diary entries. The conversion from MYR to Euro was based on the 2012 rate (1€ = MYR4). RESULTS: A total of 2900 procedures were provided, with an average cost of MYR 2820 (€705) per patient for the study year, and MYR 376 (€94) per outpatient visit. Out of this, 90% was contributed by provider cost and 10% by patient cost; 94% for direct cost and 4% for lost productivity. Treatment of aggressive periodontitis was significantly higher than for chronic periodontitis (t-test, P = 0.003). Higher costs were expended as disease severity increased (ANOVA, P = 0.022) and for patients requiring surgeries (ANOVA, P < 0.001). Providers generally spent most on consumables while patients spent most on transportation. CONCLUSIONS: Cost of providing dental treatment for periodontitis patients at public sector specialist settings were substantial and comparable with some non-communicable diseases. These findings provide basis for identifying potential cost-reducing strategies, estimating economic burden of periodontitis management and performing economic evaluation of the specialist periodontal programme.

Measures of Treatment Workload for Patients With Breast Cancer.

PURPOSE: Patients with breast cancer spend a large amount of time and effort receiving treatment. When the number of health care tasks exceeds a patient's ability to manage that workload, they could become overburdened, leading to decreased plan adherence. We used electronic health record data to retrospectively assess dimensions of treatment workload related to outpatient encounters, commuting, and admissions. METHODS: Using tumor registry and scheduling data, we evaluated the sensitivity of treatment workload measures to detect expected differences in breast cancer treatment burden by stage. We evaluated the impact of the on-body pegfilgrastim injector on the treatment workload of patients undergoing a specific chemotherapy protocol. RESULTS: As hypothesized, patients with higher stage cancer experienced higher treatment workload. Over the first 18 months after diagnosis, patients with stage III disease spent a median of 81 hours (interquartile range [IQR], 39 to 113 hours) in outpatient clinics, commuted 61 hours (IQR, 32 to 86 hours), and spent $1,432 (IQR, $690 to $2,552) in commuting costs. In contrast, patients with stage I disease spent a median of 29 hours (IQR, 18 to 46 hours in clinic), commuted for 34 hours (IQR, 19 to 55 hours), and spent $834 (IQR, $389 to $1,649) in commuting costs. In addition, we substantiated claims that the pegfilgrastim on-body injector was effective in reducing some dimensions of workload such as unique appointment days. CONCLUSION: Treatment workload measures capture an important dimension in the experience of patients with cancer. Patients and health care organizations can use workload measures to plan and allocate resources, leading to higher quality and better coordinated care.

Transportation Barriers and Use of Dental Services among Medicaid-Insured Adults.

This study explores how travel distance and other transportation barriers are associated with dental utilization in a Medicaid expansion population. We analyzed data from the Iowa Dental Wellness Plan (DWP), which provides comprehensive dental benefits for low-income adults aged 19 to 64 y as part of Iowa's Medicaid expansion. Transportation and geographical characteristics were evaluated as enabling factors within the framework of Andersen's behavioral model of health services use. In March 2015, a random sample of DWP members ( n = 4,800) was surveyed; adjusted survey response rate was 30% ( n = 1,258).The questionnaire was based on the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Dental Plan Survey and assessed need for dental care, use of dental services and transportation to visits, and self-perceived oral health status. Respondent and dentist addresses were geocoded and used to calculate distance to the nearest DWP general dentist. A logistic regression model predicting utilization of dental care was developed using variables representing each domain of the behavioral model. Most respondents (57%) reported a dental visit since enrolling. Overall, 11% of respondents reported unmet dental need due to transportation problems. Median distance to the nearest general dentist was 1.5 miles. In the adjusted model, travel distance was not significantly associated with the likelihood of dental utilization. However, other transportation-related issues were significantly associated with utilization, including concern about cost of transportation and driver/passenger status. As concern about transportation cost increased, likelihood of having a dental visit decreased. Targeted approaches to assisting low-income populations with transportation barriers should be considered in designing policies and interventions to improve access to dental care. Knowledge Transfer Statement: The results of this study can be used by policy makers and public health planners when designing programs and interventions to improve access to dental care. Consideration of transportation availability and costs could improve utilization of routine dental care, especially among low-income populations.

Clinical Teaching of Prosthodontics in Undergraduate Courses in a German Dental School: Patients, Visits, Efforts, and Incentives.

It is unknown what disadvantages are faced by patients deciding for a prosthodontic treatment by inexperienced students. Commonly, the related extra effort and time are compensated by cost reduction of treatment fees. Thereby, the dental schools subsidize treatments to teach clinical prosthodontics. The aim of this study was to clarify the benefits to patients as well as the efforts of the dental school. Data collected from three courses in a dental school in Germany were patient gender, age, occupation, zip code, number of visits, scope of treatment including costs, financial discount, and remaining copayment. Travel costs were calculated based on zip code. Balance of travel costs and treatment discount was defined as financial benefit. The results showed that 185 patients (95 male) aged 32 to 82 years (median=58) were treated with fixed restorations (FR, n=110), telescopic dentures (TD, n=87), complete dentures (CD, n=17), or other (RD, n=3). The mean number of visits was 11 for FR, 12 for TD, and 9 for CD. Single distance to the clinic ranged from 0.6 to 65 miles (median=12). Total costs of prosthodontics were reduced by 19% on average. The mean financial benefit was 429 USD (median=298, min=-482, max=4025). The financial benefits were found to differ widely, including additional expenditures of patients. Participation, travel burden, and copayment did not depend on age, gender, or occupation. The financial benefit was relativized because students needed at least twice the sessions of a dentist. As a result, the financial efforts of dental schools are significant and compromise a cost-covering education.

Direct and indirect costs of dental trauma in Sweden: a 2-year prospective study of children and adolescents.

OBJECTIVES: To study total costs, including direct costs (health care service, loss of personal property, medicine and transport) and indirect costs (loss of production or leisure) of dental trauma to children and adolescents with special reference to predictors. METHODS: The study was based on a random sample of 192 children and adolescents with a dental trauma reported to an insurance company and prospectively followed up by telephone interviews over a period of 2 years. RESULTS: On average, health care service costs represented 2,955 SEK (SD=3,818) and total costs 4,569 SEK (SD=3,053) for dental trauma to permanent teeth, and 837 SEK (SD=898) and 1,746 SEK (SD=1,183) for trauma to primary teeth. The most extensive type of indirect cost was loss of production or leisure, which averaged 1,286 SEK (SD=1,830) for injuries to permanent teeth and 699 SEK (SD=1,239) for injuries to primary teeth. Multiple regression analysis of demographic and dental injury variables showed that complicated trauma was of special importance to costs for permanent and primary teeth injuries. The average relative increase in total costs to patients and companions for complicated injury to permanent teeth was 140% (95% confidence interval [CI], 66-248%) for patients and 132% (95% CI, 54-249%) for companions. Lack of access to a dental clinic near the place of residence could increase the average total costs of injuries to permanent teeth by 91% for companions (95% CI, 20-204%) and for primary teeth by 134% (95% CI, 38-296%). CONCLUSIONS: Dental traumas result in both direct and indirect costs, with a predominance of direct costs. The direct costs primarily depend on degree of severity, while indirect costs are mostly due to compromised access to health care service. Traumas to permanent teeth are especially costly and, due to additional maintenance, the care may continue for several years. This study has drawn attention to the significant implications of dental trauma to patient and companion, a new area where further studies are warranted.

Vehicle routing for the eco-efficient collection of household plastic waste.

Plastic waste is a special category of municipal solid waste. Plastic waste collection is featured with various alternatives of collection methods (curbside/drop-off) and separation methods (source-/post-separation). In the Netherlands, the collection routes of plastic waste are the same as those of other waste, although plastic is different than other waste in terms of volume to weight ratio. This paper aims for redesigning the collection routes and compares the collection options of plastic waste using eco-efficiency as performance indicator. Eco-efficiency concerns the trade-off between environmental impacts, social issues and costs. The collection problem is modeled as a vehicle routing problem. A tabu search heuristic is used to improve the routes. Collection alternatives are compared by a scenario study approach. Real distances between locations are calculated with MapPoint. The scenario study is conducted based on real case data of the Dutch municipality Wageningen. Scenarios are designed according to the collection alternatives with different assumptions in collection method, vehicle type, collection frequency and collection points, etc. Results show that the current collection routes can be improved in terms of eco-efficiency performance by using our method. The source-separation drop-off collection scenario has the best performance for plastic collection assuming householders take the waste to the drop-off points in a sustainable manner. The model also shows to be an efficient decision support tool to investigate the impacts of future changes such as alternative vehicle type and different response rates.

Integrating multimodal transport into cellulosic biofuel supply chain design under feedstock seasonality with a case study based on California.

A multistage, mixed integer programing model was developed that fully integrates multimodal transport into the cellulosic biofuel supply chain design under feedstock seasonality. Three transport modes are considered: truck, single railcar, and unit train. The goal is to minimize the total cost for infrastructure, feedstock harvesting, biofuel production, and transportation. Strategic decisions including the locations and capacities of transshipment hubs, biorefineries, and terminals and tactical decisions on system operations are optimized in an integrated manner. When the model was implemented to a case study of cellulosic ethanol production in California, it was found that trucks are convenient for short-haul deliveries while rails are more effective for long-haul transportation. Taking the advantage of these benefits, the multimodal transport provides more cost effective solutions than the single-mode transport (truck).

Optimal configuration and combination of multiple lignocellulosic biomass feedstocks delivery to a biorefinery.

Biomass availability and transportation are major challenges in establishing a large-scale biorefinery. The objective of this study was to assess the delivery cost of different combinations of multiple forms of lignocellulosic feedstocks including agricultural and woody biomass. Three types of biomass i.e., wheat straw, corn stover and forest biomass were considered in different forms such as loose biomass, bales/bundles, chopped/chipped and pellets. It was found that the delivery cost of a combination of woody and agricultural biomass feedstocks is lower than that for a single type of biomass. The delivery of agricultural residues as bales and woody biomass as chips is an economically attractive option with optimal combination of 30% bales and 70% wood chips to a biorefinery of capacity 5000 dry tonnes per day. The anticipated traffic congestions resulting from biomass supply to a large facility could be significantly reduced by increasing the density of biomass.

Development of net energy ratio and emission factor for biohydrogen production pathways.

This study investigates the energy and environmental aspects of producing biohydrogen for bitumen upgrading from a life cycle perspective. Three technologies are studied for biohydrogen production; these include the Battelle Columbus Laboratory (BCL) gasifier, the Gas Technology Institute (GTI) gasifier, and fast pyrolysis. Three different biomass feedstocks are considered including forest residue (FR), whole forest (WF), and agricultural residue (AR). The fast pyrolysis pathway includes two cases: truck transport of bio-oil and pipeline transport of bio-oil. The net energy ratios (NERs) for nine biohydrogen pathways lie in the range of 1.3-9.3. The maximum NER (9.3) is for the FR-based pathway using GTI technology. The GHG emissions lie in the range of 1.20-8.1 kg CO2 eq/kg H2. The lowest limit corresponds to the FR-based biohydrogen production pathway using GTI technology. This study also analyzes the intensities for acid rain precursor and ground level ozone precursor.

Challenges in scaling up biofuels infrastructure.

Rapid growth in demand for lignocellulosic bioenergy will require major changes in supply chain infrastructure. Even with densification and preprocessing, transport volumes by mid-century are likely to exceed the combined capacity of current agricultural and energy supply chains, including grain, petroleum, and coal. Efficient supply chains can be achieved through decentralized conversion processes that facilitate local sourcing, satellite preprocessing and densification for long-distance transport, and business models that reward biomass growers both nearby and afar. Integrated systems that are cost-effective and energy-efficient will require new ways of thinking about agriculture, energy infrastructure, and rural economic development. Implementing these integrated systems will require innovation and investment in novel technologies, efficient value chains, and socioeconomic and policy frameworks; all are needed to support an expanded biofuels infrastructure that can meet the challenges of scale.

Economic and environmental transportation effects of large-scale ethanol production and distribution in the United States.

The combination of current and planned 2007 U.S. ethanol production capacity is 50 billion L/yr, one-third of the Energy Independence and Security Act of 2007 (EISA) target of 136 billion L of biofuels by 2022. In this study, we evaluate transportation impacts and infrastructure requirements for the use of E85 (85% ethanol, 15% gasoline) in light-duty vehicles using a combination of corn and cellulosic ethanol. Ethanol distribution is modeled using a linear optimization model. Estimated average delivered ethanol costs, in 2005 dollars, range from $0.29 to $0.62 per liter ($1.3-2.8 per gallon), depending on transportation distance and mode. Emissions from ethanol transport estimated in this work are up to 2 times those in previous ethanol LCA studies and thus lead to larger total life cycle effects. Long-distance transport of ethanol to the end user can negate ethanol's potential economic and environmental benefits relative to gasoline. To reduce costs, we recommend regional concentration of E85 blends for future ethanol production and use.

The potential for adding plastic waste fuel at a coal gasification power plant.

Plastics wastes from a municipal solid waste plant have a high energy content which make it an interesting option for co-processing with coal. The potential for adding plastic waste to a coal fired Texaco IGCC (Integrated Gasification Combined Cycle) power station is examined. The resulting efficiency increases due to the improved gasification qualities of plastic over coal. For the overall economics to be the same as the coal only case, the maximum amount that the power station can afford to spend on preparing the plastic waste for use is similar to the assumed coal cost, plus the avoided landfill cost, minus the transport cost. The location of the power station plays a key role, since this has an effect on the transport costs as well as on the landfill charges. The sensitivity of the economics of co-processing plastic waste with coal for a variety of power station operational parameters is presented.

Cost-effectiveness study of a school-based sealant program.

A nonprofit private dental clinic provides free dental treatment for children up to the age of eighteen years. In order to expand its services to reach more children, a school-based sealant program using dental auxiliary personnel was organized. This paper evaluated the performance of the school-based program during 1991 by comparing the costs of the school-based program with the costs of the sealants placed in the clinic in twelve months. Costs were calculated based on 1991 expenditures, and effectiveness rates were estimated from dental literature on sealants. The cost of saving one tooth-surface from decaying within a six-year period at the school and the clinic was $65 and $42 with an average sealing time per tooth surface of 18 and 12.5 minutes, respectively. Despite the relatively lower cost of personnel, the school program cost was 35 percent higher than at the clinic. Nevertheless, if hidden costs, such as transportation, time off work, and waiting time for those attending the clinic were considered, costs could be comparable or even higher for the clinic. The main goal of this paper is to explore a methodology to compare programs of different nature, and critically evaluate the results.

Raising children is expensive in the 1990s and beyond.

Costs of raising children continue to rise. At the same time, the marked increase in the proportion of two-earner families and single-parent families places added burdens on families to develop and pay for child care arrangements. A review is provided of current and anticipated financial costs of raising children during the 1990s and planning for the finances of their future years.