Restoring root-canal treated molars: Cost-effectiveness-analysis of direct versus indirect restorations.

OBJECTIVES: Root-canal treated molars can be directly restored, usually using resin-based-composite restorations (RBCs), or indirectly restored using full or partial crowns (FCs/PCs). Both the initial treatment costs and the risks of restorative and endodontic complications differ between RBCs and FCs/PCs. We aimed to assess the cost-effectiveness of RBCs versus FCs/PCs for restoring root-canal treated molars. METHODS: A mixed public-private payer's perspective within German healthcare was taken. Risks of complications were extracted from large cohort studies or systematic reviews. Costs were estimated using fee-items catalogues of public and private German insurance. A Markov-model was constructed to follow up a root-canal treated molar receiving different restorations in an initially 50-year-old patient over his lifetime. Monte Carlo-microsimulations were performed to assess lifetime costs and effectiveness (tooth retention time), and the resulting cost-effectiveness. RESULTS: RBCs were less costly than FCs/PCs (749 Euro versus 782 Euro), but also less effective (22 years versus 24 years), the incremental-cost-effectiveness-ratio was 10.80 Euro/year. This ratio increased if costs for direct restorations decreased, or costs for indirect restorations increased. If no teeth were replaced, RBC was far more cost-effective (the incremental cost-effectiveness ratios was 52.95 Euro/year). If all teeth were replaced, FC was both more effective and less costly. CONCLUSIONS: RBCs showed lower costs, but also lower effectiveness than FCs/PCs. Consequently, the cost-effectiveness of both strategies depended on the willingness-to-pay of patients or other payers, i.e. their willingness to invest in higher effectiveness. Clinically, a large number of tooth, patient and dentist-related factors will impact on decision-making and should be considered. CLINICAL SIGNIFICANCE: We found composite restorations to be less costly, but also less effective than indirect restorations for root-canal treated teeth. Over a long-term period, the initial treatment costs and associated cost-differences between strategies may be outweighed by costs of follow-up treatments.

Cost-effectiveness of caries-preventive fluoride varnish applications in clinic settings among patients of low, moderate and high risk.

OBJECTIVES: The total body of evidence finds fluoride varnish effective to prevent caries. However, most trials were conducted in high-risk populations, with more recent trials on low-risk groups finding a lower efficacy. We aimed to assess the cost-effectiveness of fluoride varnish application in clinic setting in populations with different caries risk. METHODS: A mixed public-private-payer perspective in the context of German health care was performed using a lifetime Markov model. Effectiveness data were derived from an update of the most recent systematic Cochrane review and synthesized in three different risk groups according to control group caries increment via random-effects meta-analysis. Varnish was assumed to be applied twice yearly between age 6 and 18 years. Teeth with carious defects would be treated restoratively and could experience further follow-up treatments. Costs were deduced from German fee item catalogues. Monte Carlo microsimulations were used for to analyse lifetime treatment costs and caries increment (Euro/Decayed, Missing, Filled Teeth (DMFT)). RESULTS: In low-risk groups, fluoride varnish was nearly twice as costly and minimally more effective (293 Euro, 8.1 DMFT) than no varnish (163 Euro, 8.5 DMFT). The incremental cost-effectiveness ratio (ICER) was 343 Euro spent per avoided DMFT. The ICER was lower in medium-risk (ICER 93 Euro/DMFT) and high-risk groups (8 Euro/DMFT). CONCLUSIONS: Application of fluoride varnish in the clinic setting is unlikely to be cost-effective in low-risk populations. There is the need to either target high-risk groups or to provide fluoride varnish at lower costs, possibly in nonclinic settings.

Cost comparison of prediction-based decision-making for periodontally affected molars.

AIM: Tooth loss prediction could improve decision-making for periodontally affected molars. We analysed the costs of removing all, none or only those molars predicted to be at-risk for extraction during supportive periodontal therapy (SPT). METHODS: This is a model-based study using a German private payer perspective. Building mainly on cost and effectiveness data from 2039 molars (301 patients) which received long-term SPT, five (exemplary) prediction/decision strategies were compared: Retaining all molars, removing molars with furcation involvement (FI) ≥ I/ ≥ II/ III, or removing all molars. Each strategy came with different proportions of molars correctly or erroneously (false positively) removed. Retaining as well as removing molars had long-term cost implications (via SPT or tooth replacement). Using Monte-Carlo microsimulations, we estimated the lifetime costs of an average population in our cohort and evaluated what accuracy a prediction method needed to have to save costs in different risk groups. RESULTS: Removing only molars with FI III (1188 Euro) and removing no molars (1195 Euro) were significantly less costly than removing all molars (1454 Euro). Prediction methods needed to be highly specific in most populations to avoid unnecessary tooth loss and the associated high costs. CONCLUSIONS: Removing molars prior to SPT should be decided cautiously.

Professional oral health care for preventing nursing home-acquired pneumonia: A cost-effectiveness and value of information analysis.

AIM: Professional oral health care (POHC) prevents nursing home-acquired pneumonia (NHAP) and its related mortality. We assessed the cost-effectiveness of POHC versus no POHC (nPOHC) and the monetary value of eliminating uncertainty by future research. METHODS: A German public-private payer perspective was adopted. A Markov model was used, following long-term care residents from admission to death. Cost-effectiveness was estimated as Euro/disability-adjusted life year (DALY) using Monte Carlo microsimulations. Value-of-information analyses were performed. The willingness-to-pay threshold/DALY was assumed to be 66% (range 50%-100%) of per-capita gross domestic product (GDP). RESULTS: nPOHC was less costly (€3,024) but also less effective (0.89 DALYs) than POHC (€10,249, 0.55 DALYs). For most presumed payers, POHC was cost-effective. The cost-effectiveness of POHC was higher in smokers, underweight or pulmonary disease patients. Eliminating uncertainty about the NHAP costs, NHAP incidence/mortality, and POHC effectiveness would result in an expected net value of 47 million €/year (and even higher values at lower GDP thresholds), and is likely to decrease with time. CONCLUSIONS: Within the chosen setting and on the basis of current evidence, POHC was cost-effective. Given the detected uncertainty, further research seems warranted.

In-Office Application of Fluoride Gel or Varnish: Cost-Effectiveness and Expected Value of Perfect Information Analysis.

Application of fluoride gel/varnish (FG/FV) reduces caries increments but generates costs. Avoiding restorative treatments by preventing caries might compensate for these costs. We assessed the cost-effectiveness of dentists applying FG/FV in office and the expected value of perfect information (EVPI). EVPI analyses estimate the economic value of having perfect knowledge, assisting research resource allocation. A mixed public-private-payer perspective in Germany was adopted. A population of 12-year-olds was followed over their lifetime, with caries increments modelled using wide intervals to reflect the uncertainty of caries risk. Biannual application of FV/FG until age 18 years was compared to no fluoride application. Effectiveness parameters and their uncertainty were derived from systematic reviews. The health outcome was caries increment (decayed, missing, or filled teeth; DMFT). Cost calculations were based on fee catalogs or microcosting, including costs for individual-prophylactic fluoridation and, for FG, an individualized tray, plus material costs. Microsimulations, sensitivity, and EVPI analyses were performed. On average and applied to a largely low-risk population, no application of fluoride was least costly but also least effective (EUR 230; 11 DMFT). FV was more costly and effective (EUR 357; 7 DMFT). FG was less effective than FV and also more costly when using individualized trays. FV was the best choice for payers willing to invest EUR 39 or more per avoided DMFT. This cost-effectiveness will differ in different settings/countries or if FG/FV is applied by other care professionals. The EVPI was mainly driven by the individual's caries risk, as FV/FG were significantly more cost-effective in high-risk populations than in low-risk ones. Future studies should focus on caries risk prediction.

Cost-effectiveness of Different Post-retained Restorations.

OBJECTIVES: Dentists can choose between metal and fiber post systems to provide post-retained restorations. The risk of tooth loss and other complications differs between different post systems, as do the initial treatment costs. We aimed to assess the cost-effectiveness of (1) cast metal (MC), (2) preformed metal (MP), (3) glass fiber (GF), and (4) carbon fiber (CF) post-retained restorations. METHODS: A mixed public-private payer's perspective within German healthcare was taken. Risks of complications were extracted from systematic reviews. Costs were estimated by using fee items and 2016 material costs. A Markov model was constructed to follow up an endodontically treated molar receiving a post-retained crown in an initially 50-year-old patient during his lifetime. Monte Carlo microsimulations were performed to assess lifetime costs and tooth retention time. RESULTS: MPs were least costly (€692€), retaining teeth for 26.7 years. GFs were more costly (€745€), retaining teeth for 27.6 years. MCs were minimally more effective but also more costly than GFs (€774€). CFs were less effective and most expensive (€825€, 26.7 years). For payers willing to invest more than €60€ per tooth retention year, GF was cost-effective. Payers willing to invest an additional €670€ found MC to be cost-effective. These findings were found robust in sensitivity analyses. CONCLUSIONS: For payers not willing to invest additional money for longer tooth retention, MP seemed most suitable to retain restorations. For payers with additional willingness to pay, GF seemed suitable, retaining teeth for longer. MC was only cost-effective under very high willingness to pay. CF is not recommendable on the basis of their cost-effectiveness.

Taxing sugar-sweetened beverages: impact on overweight and obesity in Germany.

BACKGROUND: Consumption of sugar-sweetened beverages (SSBs) increases the risk of overweight and obesity. Taxing SSBs could decrease daily energy consumption and body weight. This model-based study evaluated the impact of a 20% SSB-sales tax on overweight and obesity in the context of Germany. METHODS: The population aged 15-79 years was modelled. Taxation was assumed to affect energy consumption via demand elasticities, which affected weight and BMI. Model-based analysis was performed to estimate the tax impact on BMI in different age, gender and income groups. RESULTS: Implementing a 20% SSB tax reduced energy consumption mainly in younger age groups, males, and those with low income. Taxation decreased the mean BMI in younger groups, with the largest decrease in those aged 20-29 years, while effects in groups 60 years or above were minimal. In absolute terms, taxation was estimated to avoid 1,028,000 (-3% relative reduction) overweight individuals and 479,000 obese individuals (-4%). Overweight decreased the most in males aged 20-29 years (408,000 fewer cases /-22%), the same applied for obesity (204,000/-22%). CONCLUSIONS: An SSB tax could have significant impact on overweight and obesity, which could translate into substantial reductions of morbidity and mortality.

Cost-effectiveness of regular versus irregular supportive periodontal therapy or tooth removal.

AIM: For periodontitis patients, regular supportive periodontal therapy (SPT) decreases risks of tooth loss, with savings for tooth replacement possibly compensating SPT-costs. We aimed to assess the cost-effectiveness of regular versus irregular SPT, and to compare both strategies with immediate tooth removal. METHODS: A private payer perspective within German healthcare was adopted. A tooth-level Markov model was constructed. Replacement of 50% of removed teeth via implant-supported crowns was modelled in the base case. Cost-effectiveness was estimated as Euro/tooth retention year using Monte Carlo microsimulations. Scenario analyses were performed. RESULTS: Regular SPT was more effective (tooth retention 28.7 versus 26.1 years), but more costly (806 versus 731 Euro per tooth), with an incremental cost-effectiveness ratio (additional costs per tooth retention year) of 29 Euro/year. Regular SPT was less costly if costs for SPT per tooth and visit were <5.03 Euro, patients had high risk of tooth loss, or teeth were regularly replaced. Immediately removing and replacing teeth was usually most costly. CONCLUSIONS: Within the chosen healthcare setting and on the basis of current evidence, regular SPT retains teeth longer than irregular SPT, but does not necessarily reduce expenses. Decision-making should consider the subjective value placed on retaining teeth, the technical feasibility of replacement, and the impact of periodontal on general health.

Retention costs of periodontally compromised molars in a German population.

AIM: This study assessed the long-term costs per retention year for periodontally affected molars. METHODS: A cohort of 379 compliant subjects was retrospectively evaluated. Periodontal, restorative, endodontic, prosthetic and surgical treatment costs were estimated based on fee items of the private German health insurance. Costs/year were calculated and the impact of tooth- and subject-related factors on this cost-effectiveness ratio assessed using generalized linear-mixed modelling. RESULTS: 2306 molars received non-regenerative initial and supportive therapy and were followed until extraction or censoring (in mean (SD): 16.5 [6.8] years). Per year, 0.07 (SD: 0.12) deep scalings, 0.04 (0.11) open flap debridements, 0.01 (0.04) resective therapies and 2.49 (0.12) SPTs had been provided. Few teeth received non-periodontal treatments. Costs/year decreased significantly with each tooth a patient had at baseline (mean difference: -0.01, 95% CI: -0.02/-0.01 Euro/year), and increased with each mm of probing-pocket depth (0.04 [0.03/0.06] Euro/year), in upper (0.07 [0.11/0.31] Euro/year) or mobile molars (up to 0.33 [0.18/0.48] Euro/year), those with bone loss (up to 0.11 [0.04/0.17] Euro/year), endodontic treatment (0.24 [0.15/0.33] Euro/year), peri-apical lesions (0.24 [0.11/0.38]) and prosthetic treatment (0.54 [0.49/0.59] Euro/year). CONCLUSIONS: Annual costs for retaining periodontally affected molars were limited, and associated mainly with tooth-level factors.

Calcium Hydroxide versus Mineral Trioxide Aggregate for Direct Pulp Capping: A Cost-effectiveness Analysis.

INTRODUCTION: Recent evidence finds mineral trioxide aggregate (MTA) more effective than calcium hydroxide (CH) for direct pulp capping (DPC). The present study assessed the cost-effectiveness of MTA versus CH for DPC using a model-based simulation approach. METHODS: A mixed public/private payer perspective in the context of German health care was adopted. We modeled a permanent molar with a vital asymptomatic, exposed pulp treated via DPC with either MTA or CH. The tooth was followed over the lifetime of a 20-year-old patient using Markov models. Transition probabilities were obtained from systematically and nonsystematically collected data. The primary health outcome was tooth retention time. Costs for DPC were estimated via microcosting. Required personnel time for application was estimated using a survey among German specialized and general dentists. Material expenses were calculated based on market prices in 2015. All other costs were derived from public and private item fee catalogues. Uncertainty was introduced via probabilistic and univariate sensitivity analyses. RESULTS: DPC using MTA was both more effective and less costly (52 years retention, lifetime costs = 1368 Euro) than CH (49 years, 1527 Euro). Regardless of a payer's willingness to pay, DPC with MTA had the higher probability of being cost-effective. The identified ranking was not affected by parameter or structural uncertainty or heterogeneity. CONCLUSIONS: MTA was more cost-effective than CH for DPC despite higher initial treatment costs because expensive retreatments were avoided. Our estimates apply only on the basis of current evidence and within the chosen health care setting. From a payer's perspective, MTA should be used for DPC.

Detection and treatment of proximal caries lesions: Milieu-specific cost-effectiveness analysis.

OBJECTIVES: Dental caries lesions are highly prevalent, concentrated in high-risk groups, and often affect proximal tooth surfaces. Choosing a caries detection method determines the available treatment options: radiographically detected early lesion stages might receive non-, micro-, or invasive treatments, whilst visually tactile detected lesions are often advanced and mostly require invasive treatment. Thus, the choice of detection method impacts on patients via the applied treatment. We compared the cost-effectiveness of combinations of detections and treatments of proximal lesions in different populations which did or did not receive prevention during adolescence. These cost-effectiveness comparisons of different detection-treatment combinations should aid clinical decision making and improve resource allocation. METHODS: A Markov-model was constructed to follow a proximal posterior surface in a 12-year-old German over his lifetime. Prevalence, validity and transition probabilities were extracted from the literature. Microsimulations were performed to evaluate costs (Euro) per tooth-retention-time (years). RESULTS: For populations with low risk, radiographic detection plus non-invasive treatment without (270 Euro, 61.5 years) and with prevention (312 Euro, 63.0 years), as well as radiographic detection plus micro-invasive treatment and prevention (373 Euro, 64.0 years) were cost-effective. For populations with high risk, radiographic detection plus micro-invasive treatment without (427 Euro, 58.5 years) and with prevention (436 Euro, 61.0 years) were cost-effective. Combinations involving invasive treatments had limited cost-effectiveness. CONCLUSIONS: Caries detection methods should be evaluated regarding the cost-effectiveness resulting from their use in different populations. CLINICAL SIGNIFICANCE: Caries detection methods are usually evaluated regarding their validity compared to a gold standard. We demonstrate that the cost-effectiveness stemming from using different detection methods additionally depends on the treatment options determined by different methods, and the examined population. Dentists' choice of a detection method should not only be guided by its validity, but also by its specific benefits in different populations.

Preventing and Treating Peri-Implantitis: A Cost-Effectiveness Analysis.

BACKGROUND: A large number of treatments for peri-implantitis are available, but their cost-effectiveness remains uncertain. This study evaluates the cost-effectiveness of preventing and treating peri-implantitis. METHODS: A Markov model was constructed that followed each implant over 20 years. Supportive implant therapy (SIT) for managing peri-implant mucositis and preventing development of peri-implantitis was either provided or not. Risk of peri-implantitis was assumed to be affected by SIT and the patient's risk profile. If peri-implantitis occurred, 11 treatment strategies (non-surgical or surgical debridement alone or combined with adjunct therapies) were compared. Treatments and risk profiles determined disease progression. Modeling was performed based on systematically collected data. Primary outcomes were costs and proportion of lost implants, as assessed via Monte Carlo microsimulations. RESULTS: Not providing SIT and performing only non-surgical debridement was both least costly and least effective. The next best (more costly and effective) option was to provide SIT and perform surgical debridement (additional 0.89 euros per 1% fewer implants lost). The most effective option included bone grafts, membranes, and laser treatment (56 euros per 1%). For patients at high risk, the cost-effectiveness of SIT increased, whereas in low-risk groups, a cost-optimized strategy was cost-effective. CONCLUSIONS: Although clinical decision-making will be guided mainly by clinical condition, cost-effectiveness analyses might add another perspective. Based on these findings, an unambiguous comparative effectiveness ranking was not established. However, cost-effectiveness was predominantly determined by provision of SIT and initial treatment costs. Transferability of these findings to other healthcare systems needs further confirmation.

Secondary Treatment for Asymptomatic Root Canal Treated Teeth: A Cost-effectiveness Analysis.

INTRODUCTION: When faced with a clinically asymptomatic root canal treated tooth with certain radiographic findings (e.g., underextended or overextended root fillings or persistent periapical lesions), clinicians need to decide between endodontically retreating the tooth before restoration or not retreating it now but possibly later on. The present study compared the cost-effectiveness of both strategies. METHODS: A Markov model was constructed following a root canal treated, clinically asymptomatic molar with one of the described radiographic findings in a 50-year-old patient during his lifetime. Hazard functions were derived from systematically and non-systematically assessed literature, and costs were estimated for German health care. Monte Carlo microsimulations were performed for teeth with composite restorations, crowns, or post-core crowns, and costs per year of tooth retention were calculated. RESULTS: Regardless of the radiographic findings, not performing immediate retreatment was found to be significantly less costly (589-954 Euro) and more effective (retention time, 25-29 years) than immediately performing secondary root canal treatment (1163-1359 Euro, 25-27 years). Both strategies had similar effectiveness only for teeth that received post-core crowns, whereas immediate retreatment remained more expensive. The uncertainty around the obtained strategy ranking was low. CONCLUSIONS: The high costs for secondary root canal treatment do not seem to be outweighed by the increased risks associated with certain radiographic findings in asymptomatic teeth. Our results should be interpreted with caution because the quality of the underlying data is limited.

Cost-effectiveness of caries excavations in different risk groups - a micro-simulation study.

BACKGROUND: Whilst being the most prevalent disease worldwide, dental caries is increasingly concentrated in high-risk populations. New caries treatments should therefore be evaluated not only in terms of their cost-effectiveness in individuals, but also their effects on the distribution of costs and benefits across different populations. To treat deep caries, there are currently three strategies: selective (one-step incomplete), stepwise (two-step incomplete) and complete excavation. Building on prior research that found selective excavation generally cost-effective, we compared the costs-effectiveness of different excavations in low- and high-risk patients, hypothesizing that selective excavation had greater cost-effectiveness-advantages in patients with high compared with low risk. METHODS: An average tooth-level Markov-model was constructed following the posterior teeth in an initially 18-year old male individual, either with low or high risk, over his lifetime. Risk was assumed to be predicted by several parameters (oral hygiene, social position, dental service utilization), with evidence-based transition probabilities or hazard functions being adjusted for different risk status where applicable. Total lifetime treatment costs were estimated for German healthcare, with both mixed public-private and only private out-of-pocket costs being calculated. For cost-effectiveness-analysis, micro-simulations were performed and joint parameter uncertainty introduced by random sampling of probabilities. Cohort analyses were used for assessing the underlying reasons for potential differences between strategies and populations. RESULTS: Selective excavation was more effective and less costly than both alternatives regardless of an individual's risk. All three strategies were less effective and more costly in patients with high compared with low risk, whilst the differences between risk groups were smallest for selective excavation. Thus, the cost-effectiveness-advantages of selective excavation were more pronounced in high-risk groups, who also benefitted the most from reduced private out-of-pocket treatment costs. CONCLUSIONS: Whilst caries excavation does not tackle the underlying sources for both the development of caries lesions and the potential differences of individuals' risk status, selective excavation seems most suitable to treat deep lesions, especially in patients with high risk, who over-proportionally benefit from the resulting health-gains and cost-savings.

Retaining or replacing molars with furcation involvement: a cost-effectiveness comparison of different strategies.

AIM: The comparative cost-effectiveness of retaining or replacing molars with furcation involvement (FI) remains unclear. We assessed the cost-effectiveness of retaining FI molars via periodontal treatments versus replacing them via implant-supported crowns (ISCs). METHODS: Using tooth-level Markov models, we followed a molar with FI degree I or II/III in a 50-year-old patient over his lifetime. Tooth-retaining periodontal treatments (scaling and root planing, flap debridement, root resection, guided-tissue regeneration, tunnelling) were compared with tooth replacement using ISCs. We analysed costs, time until first re-treatment and total time of tooth or implant retention. The model adopted a private payer perspective within German health care. Transition probabilities were calculated based on current evidence. Monte-Carlo microsimulations were performed, and robustness of the model and effects of heterogeneity assessed using sensitivity analyses. RESULTS: Despite requiring re-treatment later than other strategies, ISCs were the most costly therapy. Compared with most periodontal treatments, ISCs were retained for shorter time than natural teeth regardless of the degree of FI, the patients' age or risk profile (smoker/non-smoker). CONCLUSIONS: Based on available data and within its limitations, our study indicates that retaining FI molars via periodontal treatments might be more cost-effective than replacing them via ISCs. Changes in the underlying evidence or the setting might alter these results.

Direct pulp capping after a carious exposure versus root canal treatment: a cost-effectiveness analysis.

INTRODUCTION: Excavation of deep caries often leads to pulpal exposure even in teeth with sensible, nonsymptomatic pulps. Although direct pulp capping (DPC) aims to maintain pulpal health, it frequently requires follow-up treatments like root canal treatment (RCT), which could have been performed immediately after the exposure, with possibly improved outcomes. We quantified and compared the long-term cost-effectiveness of both strategies. METHODS: A Markov model was constructed following a molar with an occlusally located exposure of a sensible, nonsymptomatic pulp in a 20-year-old male patient over his lifetime. Transition probabilities or hazard functions were estimated based on systematically and nonsystematically assessed literature. Costs were estimated based on German health care, and cost-effectiveness was analyzed using Monte Carlo microsimulations. RESULTS: Despite requiring follow-up treatments significantly earlier, teeth treated by DPC were retained for long periods of time (52 years) at significantly reduced lifetime costs (545 vs 701 Euro) compared with teeth treated by RCT. For teeth with proximal instead of occlusal exposures or teeth in patients >50 years of age, this cost-effectiveness ranking was reversed. Although sensitivity analyses found substantial uncertainty regarding the effectiveness of both strategies, DPC was usually found to be less costly than RCT. CONCLUSIONS: We found both DPC and RCT suitable to treat exposed vital, nonsymptomatic pulps. DPC was more cost-effective in younger patients and for occlusal exposure sites, whereas RCT was more effective in older patients or teeth with proximal exposures. These findings might change depending on the health care system and underlying literature-based probabilities.

Costs and effectiveness of treatment alternatives for proximal caries lesions.

OBJECTIVES: Invasive therapy of proximal caries lesions initiates a cascade of re-treatment cycles with increasing loss of dental hard tissue. Non- and micro-invasive treatment aim at delaying this cascade and may thus reduce both the health and economic burden of such lesions. This study compared the costs and effectiveness of alternative treatments of proximal caries lesions. METHODS: A Markov-process model was used to simulate the events following the treatment of a proximal posterior lesion (E2/D1) in a 20-year-old patient in Germany. We compared three interventions (non-invasive; micro-invasive using resin infiltration; invasive using composite restoration). We calculated the risk of complications of initial and possible follow-up treatments and modelled time-dependent non-linear transition probabilities. Costs were calculated based on item-fee catalogues in Germany. Monte-Carlo-microsimulations were performed to compare cost-effectiveness of non- versus micro-invasive treatment and to analyse lifetime costs of all three treatments. RESULTS: Micro-invasive treatment was both more costly and more effective than non-invasive therapy, with ceiling-value-thresholds for willingness-to-pay between 16.73 € for E2 and 1.57 € for D1 lesions. Invasive treatment was the most costly strategy. Calculated costs and effectiveness were sensitive to lesion stage, patient's age, discounting rate and assumed initial treatment costs. CONCLUSIONS: Non- and micro-invasive treatments have lower long-term costs than invasive therapy of proximal lesions. Micro-invasive therapy had the highest cost-effectiveness for treating D1 lesions in young patients. Decision makers with a willingness-to-pay over 16.73 € and 1.57 € for E2 and D1 lesions, respectively, will find micro-invasive treatment more cost-effective than non-invasive therapy.

Transitivity in health utility measurement: An experimental analysis.

Several experimental studies have observed substantial violations of transitivity for decisions between risky lotteries over monetary outcomes. The goal of our experiment is to test whether these violations also affect the evaluation of health states. A particular feature of our experimental design is that it takes into account the possible role of decision errors for generating violations of transitivity. Since we find neither substantial nor systematic deviations from transitive choice behaviour, we can conclude that previously reported violations do not seem to bias health utility measurement.

The impact of new drug launches on the loss of labor from disease and injury: evidence from German panel data.

We study the impact of new drug launches on early retirement due to disease and injury in the German labor force between 1988 and 2004. We show that new drug launches have substantially helped to reduce the loss of labor at the disease-level over time. In Western Germany alone, each new chemical entity is estimated to have saved on average around 200 working years in every year of the observation period. Controlling for individual determinants of retirement, the 2001 reform of pension laws appears to have led to further reductions in the loss of labor from disease and injury.

The welfare costs of HIV/AIDS in eastern Europe: an empirical assessment using the economic value-of-life approach.

Based on the aggregation of individual willingness-to-pay for a statistical life, we calibrate an inter-temporal optimisation model to determine the aggregate welfare loss from HIV/AIDS in 25 Eastern European countries. Assuming a discount rate of 3%, we find a total welfare loss for the whole region that exceeds US $800 billion, approximately 10% of the region's annual GDP between 1995 and 2001. Although prevalence and incidence rates diverge sharply between countries-with central Europe far less affected than major countries in the Commonwealth of Independent States and the Baltics-the epidemic is likely to spread to all countries unless a coherent strategy of prevention and treatment is backed up by substantial increases in healthcare investments. The sheer size of this task and the international nature of the epidemic render this one of the most important current challenges for all of Europe.