Cost-effectiveness of screening for chronic kidney disease using a cumulative eGFR-based statistic.

OBJECTIVES: Routine screening for chronic kidney disease (CKD) could enable timely interventions to slow down disease progression, but currently there are no clinical guidelines for screening. We aim to evaluate the cost-effectiveness of screening for CKD using a novel analytical tool based on a cumulative sum statistic of estimated glomerular filtration rate (CUSUMGFR). METHODS: We developed a microsimulation model that captured CKD disease progression, major complications, patients' awareness, and treatment adherence for a nationally representative synthetic cohort of age ≥ 30 years in the United States. In addition to the status quo with no screening, we considered four CUSUMGFR-based universal screening policies by frequency (annual or biennial) and starting age (30 or 60 years), and two targeted annual screening policies for patients with hypertension and diabetes, respectively. For each policy, we evaluated the total discounted disability-adjusted life years (DALYs) and direct health costs over a lifetime horizon and estimated the incremental cost-effectiveness ratio (ICER). We further performed one-way and probabilistic sensitivity analyses to assess the impact of parameter uncertainty. RESULTS: Compared with the status quo, all the CUSUMGFR-based screening policies were cost-effective under the willingness-to-pay (WTP) range of $50,000 -$100,000, with the estimated incremental cost-effectiveness ratios (ICERs) ranging from $15,614/DALYs averted to $54,373/DALYs averted. Universal annual screening with starting age of 30 was the non-dominated policy on the cost-effectiveness frontier under the WTP of approximately $25,000. Adding more recent treatment option of sodium-glucose cotransporter-2 (SGLT2) inhibitors to the treatment regimen was found to be cost-saving. Among the most influential model parameters, variation in the CKD progression rate, adherence, and testing cost resulted in the highest variability in model outcomes. CONCLUSIONS: CUSUMGFR-based screening policies for CKD are highly cost-effective in identifying patients at risk of end stage kidney disease in early stages of CKD. Given its simple requirement of a basic blood test, the CUSUMGFR-based screening can be easily incorporated into clinical workflow for disease monitoring and prevention.

Expanding the Geographic Boundaries of Melioidosis in Queensland, Australia.

Melioidosis is an infectious disease caused by the bacterium Burkholderia pseudomallei. Although this environmental organism is endemic in certain regions of Australia, it is not considered endemic in Southern Queensland, where the last case was reported 21 years ago. We report a climate change-associated outbreak of melioidosis occurring during two La Niña events in a region previously considered nonendemic for B. pseudomallei. During a 15-month period, 14 cases of locally acquired melioidosis were identified. Twelve patients were adults (> 50 years), with diabetes mellitus the most common risk factor in 6 of 12 patients (50%). Eleven patients (79%) had direct exposure to floodwaters or the flooded environment. This study suggests an association between climate change and an increased incidence of melioidosis. In addition, this is the first report of environmental sampling and whole-genome analysis to prove endemicity and local acquisition in this region.

Opioid-Related Treatment Disparities Among Medicaid Enrollees in Indiana.

Introduction: Health care disparities based on race/ethnicity and sex can be found in a variety of settings. Our aim is to determine if there are disparities in treatment provided to Indiana Medicaid enrollees who have medically documented opioid use. Study Data and Methods: We used Medicaid reimbursement claims data to extract patients who were diagnosed with opioid use disorder (OUD) or had other medical event related to opioid use between January 2018 and March 2019. We used a two-proportion Z-test to verify the difference in the proportion of treatment provided between population subgroups. The study was approved by the Purdue University Institutional Review Board (2019-118). Study Results: Over the study period, there were 52,994 Indiana Medicaid enrollees diagnosed with OUD or documentation of another opioid related event. Only 5.41% of them received at least one type of treatment service (detoxification, psychosocial, medication assisted treatment, or comprehensive). Discussion: Although Medicaid began covering treatment services for enrollees with an OUD in Indiana at the start of 2018, very few received evidence-based services. Men and White enrollees with an OUD were in general more likely to receive services compared to women and non-White enrollees.

Disability-Adjusted Life-Years for Drug Overdose Crisis and COVID-19 Are Comparable During the Two Years of Pandemic in the United States.

OBJECTIVES: The drug overdose crisis with shifting patterns from primarily opioid to polysubstance uses and COVID-19 infections are 2 concurrent public health crises in the United States, affecting the population of sizes in different magnitudes (approximately < 10 million for substance use disorder [SUD] and drug overdoses vs 80 million for COVID-19 within 2 years of the pandemic). Our objective is to compare the relative scale of disease burden for the 2 crises within a common framework, which could help inform policy makers with resource allocation and prioritization strategies. METHODS: We calculated disability-adjusted life-years (DALYs) for SUD (including opioids and stimulants) and COVID-19 infections, respectively. We collected estimates for SUD prevalence, overdose deaths, COVID-19 cases and deaths, disability weights, and life expectancy from multiple publicly available sources. We then compared age distributions of estimated DALYs. RESULTS: We estimated a total burden of 13.83 million DALYs for SUD and drug overdoses and 15.03 million DALYs for COVID-19 in 2 years since March 2020. COVID-19 burden was dominated by the fatal burden (> 95% of total DALYs), whereas SUD burden was attributed to both fatal (53%) and nonfatal burdens (47%). The highest disease burden was among individuals aged 30 to 39 years for SUD (27%) and 50 to 64 years for COVID-19 (31%). CONCLUSIONS: Despite the smaller size of the affected population, SUD and drug overdoses resulted in comparable disease burden with the COVID-19 pandemic. Additional resources supporting evidence-based interventions in prevention and treatment may be warranted to ameliorate SUD and drug overdoses during both the pandemic and postpandemic recovery.

Estimating the impact of neonatal abstinence system interventions on Medicaid: an incremental cost analysis.

BACKGROUND: Neonatal abstinence syndrome (NAS) incidence has significantly increased in the US in recent years. It is therefore important to develop effective intervention protocols that mitigate the long-term consequences of this condition for the mother, her child, and the community. METHODS: We used Monte Carlo simulation to estimate the impact of four interventions for NAS and their combinations on pregnant women with opioid use disorder. The key outputs were changes in incremental costs from baseline from the Medicaid perspective and from a total systems perspective and effect size changes. Simulation parameters and costs were based on the literature and baseline model validation was performed using Medicaid claims for Indiana. RESULTS: Compared to baseline, the resulting simulation estimates showed that three interventions significantly decreased Medicaid incremental costs by 8% (mandatory opioid testing (MOT)), 4% (patient navigators), and 3% (peer recovery coaches). The combination of the three interventions reduced Medicaid direct costs by 26%. Reductions were similar for total system incremental costs (ranging from 2 to 24%), though MOT was found to increase costs of overdose death based on productivity loss. NAS case reductions ranged from 1% (capacity change) to 13% (MOT). CONCLUSIONS: Using systems-based modeling, we showed that costs associated with NAS can be significantly reduced. However, effective implementation would require the involvement and coordination of several stakeholders. In addition, careful protocols for MOT should be considered to ensure pregnant women don't forgo prenatal care for fear of punitive consequences.

Assessing school-based policy actions for COVID-19: An agent-based analysis of incremental infection risk.

Many schools and universities have seen a significant increase in the spread of COVID-19. As such, a number of non-pharmaceutical interventions have been proposed including distancing requirements, surveillance testing, and updating ventilation systems. Unfortunately, there is limited guidance for which policy or set of policies are most effective for a specific school system. We develop a novel approach to model the spread of SARS-CoV-2 quanta in a closed classroom environment that extends traditional transmission models that assume uniform mixing through air recirculation by including the local spread of quanta from a contagious source. In addition, the behavior of students with respect to guideline compliance was modeled through an agent-based simulation. Estimated infection rates were on average lower using traditional transmission models compared to our approach. Further, we found that although ventilation changes were effective at reducing mean transmission risk, it had much less impact than distancing practices. Duration of the class was an important factor in determining the transmission risk. For the same total number of semester hours for a class, delivering lectures more frequently for shorter durations was preferable to less frequently with longer durations. Finally, as expected, as the contact tracing level increased, more infectious students were identified and removed from the environment and the spread slowed, though there were diminishing returns. These findings can help provide guidance as to which school-based policies would be most effective at reducing risk and can be used in a cost/comparative effectiveness estimation study given local costs and constraints.

Assessing the impact of Indiana legislation on opioid-based doctor shopping among Medicaid-enrolled pregnant women: a regression analysis.

BACKGROUND: States have passed various legislative acts in an attempt to reduce opioid prescribing and corresponding doctor shopping, including prescription drug monitoring programs. This study seeks to determine the association between two state-based interventions enacted in Indiana and the level of doctor shopping among Medicaid-enrolled pregnant women. METHODS: Indiana Medicaid claims data over the period of January 2014 to March 2019 were used in a regression model to determine the longitudinal change in percentage of pregnant women engaged in doctor shopping based on passage of Indiana Administrative Code Title 884 in 2014 and Public Law 194 in 2018. The primary reasons for prescribing were also identified. RESULTS: There were 37,451 women that had both pregnancy and prescription opioid claims over the time horizon. Of these, 2130 women met the criteria for doctor shopping. Doctor shopping continued to increase over the time between the passage of the two interventions but decreased after passage of Public Law 194. CONCLUSION: The decrease in doctor shopping among Medicaid-enrolled pregnant women after passage of Public Law 194 points to the importance of addressing this issue across a broad set of healthcare professionals including nurse practitioners and physician assistants. It is also possible that the potential punitive component in the Law for non-compliance played a role.

Return on investment of self-management education and home visits for children with asthma.

OBJECTIVE: Priorities of the Centers for Disease Control and Prevention's 6|18 Initiative include outpatient asthma self-management education (ASME) and home-based asthma visits (home visit) as interventions for children with poorly-controlled asthma. ASME and home visit intervention programs are currently not widely available. This project was to assess the economic sustainability of these programs for state asthma control programs reimbursed by Medicaid. METHODS: We used a simulation model based on parameters from the literature and Medicaid claims, controlling for regression to the mean. We modeled scenarios under various selection criteria based on healthcare utilization and age to forecast the return on investment (ROI) using data from New York. The resulting tool is available in Excel or Python. RESULTS: Our model projected health improvement and cost savings for all simulated interventions. Compared against home visits alone, the simulated ASME alone intervention had a higher ROI for all healthcare utilization and age scenarios. Savings were primarily highest in simulated program participants who had two or more asthma-related emergency department visits or one inpatient visit compared to those participants who had one or more asthma-related emergency department visits. Segmenting the selection criteria by age did not significantly change the results. CONCLUSIONS: This model forecasts reduced healthcare costs and improved health outcomes as a result of ASME and home visits for children with high urgent healthcare utilization (more than two emergency department visits or one inpatient hospitalization) for asthma. Utilizing specific selection criteria, state based asthma control programs can improve health and reduce healthcare costs.

Unpacking Prevalence and Dichotomy in Quick Sequential Organ Failure Assessment and Systemic Inflammatory Response Syndrome Parameters: Observational Data-Driven Approach Backed by Sepsis Pathophysiology.

BACKGROUND: Considering morbidity, mortality, and annual treatment costs, the dramatic rise in the incidence of sepsis and septic shock among intensive care unit (ICU) admissions in US hospitals is an increasing concern. Recent changes in the sepsis definition (sepsis-3), based on the quick Sequential Organ Failure Assessment (qSOFA), have motivated the international medical informatics research community to investigate score recalculation and information retrieval, and to study the intersection between sepsis-3 and the previous definition (sepsis-2) based on systemic inflammatory response syndrome (SIRS) parameters. OBJECTIVE: The objective of this study was three-fold. First, we aimed to unpack the most prevalent criterion for sepsis (for both sepsis-3 and sepsis-2 predictors). Second, we intended to determine the most prevalent sepsis scenario in the ICU among 4 possible scenarios for qSOFA and 11 possible scenarios for SIRS. Third, we investigated the multicollinearity or dichotomy among qSOFA and SIRS predictors. METHODS: This observational study was conducted according to the most recent update of Medical Information Mart for Intensive Care (MIMIC-III, Version 1.4), the critical care database developed by MIT. The qSOFA (sepsis-3) and SIRS (sepsis-2) parameters were analyzed for patients admitted to critical care units from 2001 to 2012 in Beth Israel Deaconess Medical Center (Boston, MA, USA) to determine the prevalence and underlying relation between these parameters among patients undergoing sepsis screening. We adopted a multiblind Delphi method to seek a rationale for decisions in several stages of the research design regarding handling missing data and outlier values, statistical imputations and biases, and generalizability of the study. RESULTS: Altered mental status in the Glasgow Coma Scale (59.28%, 38,854/65,545 observations) was the most prevalent sepsis-3 (qSOFA) criterion and the white blood cell count (53.12%, 17,163/32,311 observations) was the most prevalent sepsis-2 (SIRS) criterion confronted in the ICU. In addition, the two-factored sepsis criterion of high respiratory rate (≥22 breaths/minute) and altered mental status (28.19%, among four possible qSOFA scenarios besides no sepsis) was the most prevalent sepsis-3 (qSOFA) scenario, and the three-factored sepsis criterion of tachypnea, high heart rate, and high white blood cell count (12.32%, among 11 possible scenarios besides no sepsis) was the most prevalent sepsis-2 (SIRS) scenario in the ICU. Moreover, the absolute Pearson correlation coefficients were not significant, thereby nullifying the likelihood of any linear correlation among the critical parameters and assuring the lack of multicollinearity between the parameters. Although this further bolsters evidence for their dichotomy, the absence of multicollinearity cannot guarantee that two random variables are statistically independent. CONCLUSIONS: Quantifying the prevalence of the qSOFA criteria of sepsis-3 in comparison with the SIRS criteria of sepsis-2, and understanding the underlying dichotomy among these parameters provides significant inferences for sepsis treatment initiatives in the ICU and informing hospital resource allocation. These data-driven results further offer design implications for multiparameter intelligent sepsis prediction in the ICU.

Quantifying the Impact of Acute Stroke System of Care Transfer Protocols on Patient Outcomes.

BACKGROUND: We quantify the impact of implementing a stroke system of care requiring transport of individuals believed to have stroke to a primary stroke center, in rural and urban settings, based on time from symptom recognition to treatment, probability of receiving treatment within 3 hours of stroke onset, and probability of overcrowding. We use Indiana as an example. METHODS: We used discrete-event simulation to estimate outcomes for 2 scenarios: stroke system of care with enabling technology (mobile stroke unit, stroke team expansion) and stroke system of care with no enabling technology, as compared with the status quo. We considered patient flow from symptom recognition to treatment. Patient locations and stroke events were generated for the 92 Indiana counties in Indiana, subdivided into 1009 locations. We considered time from emergency medical service (EMS) arrival at onset to treatment, probability of tissue plasminogen activator administered within 3 h of onset, and percentage of patients admitted beyond the occupancy level at the comprehensive stroke center. RESULTS: Results varied by urbanicity. Under no enabling technology, having a stroke system of care improved outcomes for individuals in urban and suburban settings. However, in rural settings, the implementation of stroke system of care guidelines decreased the average rate of treatment within 3 h of stroke onset and increased the EMS arrival to treatment times compared with sending the individual to the closest provider. Enabling technologies improved outcomes regardless of setting. DISCUSSION: Geographic disparities tend to increase the number of transfers, decrease the rate of treatment within 3 h of onset, and increase transit time. This could be overcome through federal and state initiatives to reduce quality gaps in stroke care in rural settings and promote care with dedicated stroke wards.

Engineering Approaches for Addressing Opioid Use Disorder in the Community.

Many communities in the United States are struggling to deal with the negative consequences of illicit opioid use. Effectively addressing this epidemic requires the coordination and support of community stakeholders in a change process with common goals and objectives, continuous engagement with individuals with opioid use disorder (OUD) through their treatment and recovery journeys, application of systems engineering principles to drive process change and sustain it, and use of a formal evaluation process to support a learning community that continuously adapts. This review presents strategies to improve OUD treatment and recovery with a focus on engineering approaches grounded in systems thinking.

Data-driven modeling of diabetes care teams using social network analysis.

OBJECTIVE: We assess working relationships and collaborations within and between diabetes health care provider teams using social network analysis and a multi-scale community detection. MATERIALS AND METHODS: Retrospective analysis of claims data from a large employer over 2 years was performed. The study cohort contained 827 patients diagnosed with diabetes. The cohort received care from 2567 and 2541 health care providers in the first and second year, respectively. Social network analysis was used to identify networks of health care providers involved in the care of patients with diabetes. A multi-scale community detection was applied to the network to identify groups of health care providers more densely connected. Social network analysis metrics identified influential providers for the overall network and for each community of providers. RESULTS: Centrality measures identified medical laboratories and mail-order pharmacies as the central providers for the 2 years. Seventy-six percent of the detected communities included primary care physicians, and 97% of the communities included specialists. Pharmacists were detected as central providers in 24% of the communities. DISCUSSION: Social network analysis measures identified the central providers in the network of diabetes health care providers. These providers could be considered as influencers in the network that could enhance the implication of promotion programs through their access to a large number of patients and providers. CONCLUSION: The proposed framework provides multi-scale metrics for assessing care team relationships. These metrics can be used by implementation experts to identify influential providers for care interventions and by health service researchers to determine impact of team relationships on patient outcomes.

Projecting the economic impact of silver diamine fluoride on caries treatment expenditures and outcomes in young U.S. children.

OBJECTIVE: To quantify the economic impact of using silver diamine fluoride (SDF) to arrest the progression of dental caries in Medicaid-enrolled children (aged 1-5 years) relative to the standard restorative treatment from the Medicaid programs' perspective. METHODS: We used Monte Carlo simulation to estimate averted restorative visits and associated expenditures for varying SDF effectiveness and intervention penetration levels. We compared the current standard of care for treating caries to applying SDF. We estimated expenditures from the 2010-2012 Medicaid Analytic Extract files for seven US states and the incremental cost effectiveness ratio for SDF application on averted restorative visits. RESULTS: Across the seven states, averted restorative visits ranged from 2,049 (Vermont) to 60,542 (North Carolina), assuming an SDF penetration level of 50%. Averted per-restorative visit costs ranged from $100 to $350 per-visit. There were higher averted per-restorative visit costs in nonmetropolitan counties than metropolitan counties. CONCLUSIONS: Providing SDF as a caries management strategy can reduce Medicaid program dental care expenditures by averting expensive caries treatment options. It could also prevent stressful restorative procedures. State Medicaid programs should consider reimbursing for SDF to arrest the progression of dental caries in young children.

Changes in Older Adults' Oral Health and Disparities: 1999 to 2004 and 2011 to 2016.

OBJECTIVES: To examine changes in tooth loss and untreated tooth decay among older low-income and higher-income US adults and whether disparities have persisted. DESIGN: Sequential cross-sectional study using nationally representative data. SETTING: The 1999 to 2004 and 2011 to 2016 National Health and Nutrition Examination Survey. PARTICIPANTS: Noninstitutionalized US adults, aged 65 years and older (N = 3539 for 1999-2004, and N = 3514 for 2011-2016). MEASUREMENTS: Differences in prevalence of tooth loss (having 19 teeth or fewer, 8 teeth or fewer, and no teeth) and untreated decay and mean number of decayed and missing teeth (DMT) between low- and high-income adults 65 years and older in each survey and changes between surveys. Adjusted prevalence and count outcomes were estimated with logistic and negative binomial regression models, respectively. Models controlled for sociodemographic characteristics and smoking status. Reported findings are significant at P < .05. RESULTS: In 2011 to 2016, unadjusted prevalence of having 19 teeth or fewer, 8 teeth or fewer, no teeth, and untreated decay among low-income adults 65 years and older was 50.6%, 42.0%, 28.6%, and 28.6%, respectively. Multivariate analyses indicated that although most tooth loss measures improved between surveys for both income groups, tooth loss among low-income adults remained at almost twice that among higher-income adults. The disparity in untreated decay prevalence in 2011 to 2016, 15.2 percentage points (26.1% vs 10.9% for low vs high income) was twice that in 1999 to 2004, 8.5 percentage points (22.9% vs 14.4% for low vs high income). DMT decreased for both groups, with lower-income adults having about five more affected teeth in both surveys. CONCLUSION: Tooth loss is decreasing, but differential access to restorative care by income appears to have increased.

Qualitative study investigating the underlying motivations of healthy participants in phase I clinical trials.

OBJECTIVES: If patients are to reap the benefits of continued drug development, an understanding of why healthy participants take part in phase I clinical trials is imperative. The current study aimed to explore the nature of these underlying motivations which may, in turn, improve the overall participant experience and assist in the development of more effective recruitment and retention strategies. DESIGN: This study used a qualitative design based on the theory of planned behaviour. Specifically, it explored healthy participants' underlying behavioural, control and normative beliefs which influence their participation in phase I clinical trials. SETTING: This study took place at a company that specialises in conducting phase I and phase II clinical trials in the Australian state of Queensland. PARTICIPANTS: Participants (n=31) were either currently undergoing a phase I clinical trial or had previously taken part in a phase I clinical trial. RESULTS: Results showed that the motivations were varied and not solely centred on financial gains. Reported advantages of participation included altruism, while inconvenience was most often reported as a disadvantage. Friends were reported as those most likely to approve, while one's mother was reported as most likely to disapprove. Having a suitable time frame/flexible scheduling and feeling comfortable taking part in the trial were both the most commonly reported facilitators, while inflexible scheduling/time commitment was the most commonly reported barrier. CONCLUSIONS: Practical implications included the need for organisations involved in clinical trials to be mindful of inflexible scheduling and exploring the possibility of making educational materials available to family members who may be concerned about the risks associated with participation. Overall, it is anticipated that the results of this study will improve the understanding of factors that influence phase I clinical trial participation which may, ultimately, help develop new therapeutics to improve patient health.

Estimating the Cost Savings of Preventive Dental Services Delivered to Medicaid-Enrolled Children in Six Southeastern States.

OBJECTIVE: To quantify the impact of multiyear utilization of preventive dental services on downstream dental care utilization and expenditures for children. DATA SOURCES/STUDY SETTING: We followed 0.93 million Medicaid-enrolled children who were 3-6 years old in 2005 from 2005 to 2011. We used Medicaid claims data of Alabama, Georgia, Mississippi, North Carolina, South Carolina, and Texas. STUDY DESIGN: We clustered each state's study population into four groups based on utilization of topical fluoride and dental sealants before caries-related treatment using machine learning algorithms. We evaluated utilization rates and expenditures across the four groups and quantified cost savings of preventive care for different levels of penetration. DATA EXTRACTION METHOD: We extracted all dental-related claims using CDT codes. PRINCIPAL FINDINGS: In all states, Medicaid expenditures were much lower for children who received topical fluoride and dental sealants before caries development than for all other children, with a per-member per-year difference ranging from $88 for Alabama to $156 for Mississippi. CONCLUSIONS: The cost savings from topical fluoride and sealants across the six states ranged from $1.1M/year in Mississippi to $12.9M/year in Texas at a 10 percent penetration level. Preventive dental care for children not only improves oral health outcomes but is also cost saving.

Disparities in Preventive Dental Care Among Children in Georgia.

INTRODUCTION: We compared access to preventive dental care among low-income children eligible for public dental insurance to access among children with private dental insurance and/or high family income (>400% of the federal poverty level) in Georgia, and the effect of policies toward increasing access to dental care for low-income children. METHODS: We used multiple sources of data (eg, US Census, Georgia Board of Dentistry) to estimate, by census tract, measures of preventive dental care access in 2015 for children aged 0 to 18 years. Measures were percentage of met need, 1-way travel distance to a dentist, and scarcity of dentists. We used an optimization model to estimate access, quantify disparities, and evaluate policies. RESULTS: About 1.5 million children were eligible for public insurance; 600,000 had private insurance and/or high family income. Across census tracts, average met need was 59% for low-income children and 96% for high-income children; for rural census tracts, these values were 33% and 84%, respectively. The average 1-way travel distance for all census tracts was 3.7 miles for high-income and/or privately insured children and 17.2 miles for low-income children; for rural census tracts, these values were 11.6 and 32.9 miles, respectively. Increasing dentists' acceptance of public insurance-eligible children increased met need more in rural areas than in urban areas. To achieve 100% met need in rural tracts, however, an 80% participation rate among dentists would be required. CONCLUSION: Across census tracts, high-income children had better access to preventive dental care than low-income children had. Identifying tracts with disparities in access could result in more efficient allocation of public health dental resources.

The cost-effectiveness of three interventions for providing preventive services to low-income children.

OBJECTIVE: We evaluated the impact of loan repayment programmes, revising Medicaid fee-for-service rates, and changing dental hygienist supervision requirements on access to preventive dental care for children in Georgia. METHODS: We estimated cost savings from the three interventions of preventive care for young children after netting out the intervention cost. We used a regression model to evaluate the impact of changing the Medicaid reimbursement rates. The impact of supervision was evaluated by comparing general and direct supervision in school-based dental sealant programmes. RESULTS: Federal loan repayments to dentists and school-based sealant programmes (SBSPs) had lower intervention costs (with higher potential cost savings) than raising the Medicaid reimbursement rate. General supervision had costs 56% lower than direct supervision of dental hygienists for implementing a SBSP. Raising the Medicaid reimbursement rate by 10 percentage points would improve utilization by <1% and cost over $38 million. Given one parameter set, SBSPs could serve over 27 000 children with an intervention cost between $500 000 and $1.3 million with a potential cost saving of $1.1 million. Loan repayment could serve almost 13 000 children for a cost of $400 000 and a potential cost saving of $176 000. CONCLUSIONS: The three interventions all improved met need for preventive dental care. Raising the reimbursement rate alone would marginally affect utilization of Medicaid services but would not substantially increase acceptance of Medicaid by providers. Both loan repayment programmes and amending supervision requirements are potentially cost-saving interventions. Loan repayment programmes provide complete care to targeted areas, while amending supervision requirements of dental hygienists could provide preventive care across the state.

Estimating Demand for and Supply of Pediatric Preventive Dental Care for Children and Identifying Dental Care Shortage Areas, Georgia, 2015.

OBJECTIVES: Demand for dental care is expected to outpace supply through 2025. The objectives of this study were to determine the extent of pediatric dental care shortages in Georgia and to develop a general method for estimation that can be applied to other states. METHODS: We estimated supply and demand for pediatric preventive dental care for the 159 counties in Georgia in 2015. We compared pediatric preventive dental care shortage areas (where demand exceeded twice the supply) designated by our methods with dental health professional shortage areas designated by the Health Resources & Services Administration. We estimated caries risk from a multivariate analysis of National Health and Nutrition Examination Survey data and national census data. We estimated county-level demand based on the time needed to perform preventive dental care services and the proportion of time that dentists spend on pediatric preventive dental care services from the Medical Expenditure Panel Survey. RESULTS: Pediatric preventive dental care supply exceeded demand in Georgia in 75 counties: the average annual county-level pediatric preventive dental care demand was 16 866 hours, and the supply was 32 969 hours. We identified 41 counties as pediatric dental care shortage areas, 14 of which had not been designated by the Health Resources & Services Administration. CONCLUSIONS: Age- and service-specific information on dental care shortage areas could result in more efficient provider staffing and geographic targeting.