Evaluation of the Clinical, Technical, and Financial Aspects of Cost-Effectiveness Analysis of Artificial Intelligence in Medicine: Scoping Review and Framework of Analysis.

BACKGROUND: Cost-effectiveness analysis of artificial intelligence (AI) in medicine demands consideration of clinical, technical, and economic aspects to generate impactful research of a novel and highly versatile technology. OBJECTIVE: We aimed to systematically scope existing literature on the cost-effectiveness of AI and to extract and summarize clinical, technical, and economic dimensions required for a comprehensive assessment. METHODS: A scoping literature review was conducted to map medical, technical, and economic aspects considered in studies on the cost-effectiveness of medical AI. Based on these, a framework for health policy analysis was developed. RESULTS: Among 4820 eligible studies, 13 met the inclusion criteria for our review. Internal medicine and emergency medicine were the clinical disciplines most frequently analyzed. Most of the studies included were from the United States (5/13, 39%), assessed solutions requiring market access (9/13, 69%), and proposed optimization of direct resources as the most frequent value proposition (7/13, 53%). On the other hand, technical aspects were not uniformly disclosed in the studies we analyzed. A minority of articles explicitly stated the payment mechanism assumed (5/13, 38%), while it remained unspecified in the majority (8/13, 62%) of studies. CONCLUSIONS: Current studies on the cost-effectiveness of AI do not allow to determine if the investigated AI solutions are clinically, technically, and economically viable. Further research and improved reporting on these dimensions seem relevant to recommend and assess potential use cases for this technology.

Oral health care in Europe: Financing, access and provision.

With growing awareness of the large burden of oral diseases and how limited coverage affects both access and affordability, oral health policy has been receiving increased attention in recent years. This culminated in the adoption of the WHO resolution on Oral Health in 2021, which urges Member States to better integrate oral health into their universal health coverage and noncommunicable disease agendas. This study investigates major patterns and developments in oral health status, financing, coverage, access, and service provision of oral health care in 31 European countries. While most countries cover oral health care for vulnerable population groups, the level of statutory coverage varies widely across Europe resulting in different coverage and financing schemes for the adult population. On average, one third of dental care spending is borne by public sources and the remaining part is paid out-of-pocket or by voluntary health insurance. This has important ramifications for financial protection and access to care, leaving many dental problems untreated. Overall, unmet needs for dental care are higher than for other types of care and particularly affect low-income groups. Dental care is undergoing various structural changes. The number of dentists is increasing, and the composition of the health workforce is starting to change in many countries. Dental care is increasingly provided in group practices and by practices that are part of private equity firms. Although there are (early) signs of a shift towards more preventive therapies and policies of oral diseases, dental care overall remains focused on treatment. A lack of data affects all areas of oral health care. Current health information systems only collect very few indicators on oral health and oral health care. An improved evidence base would allow more meaningful assessments and comparisons of oral health systems performance. This in turn would allow better informed policy decisions and enable better targeted and more effective oral health interventions.

Oral health care in Europe: financing, access and provision

With growing awareness of the large burden of oral diseases and how limited coverage affects both access and affordability, oral health policy has been receiving increased attention in recent years. This culminated in the adoption of the WHO resolution on Oral Health in 2021, which urges Member States to better integrate oral health into their universal health coverage and noncommunicable disease agendas. This study investigates major patterns and developments in oral health status, financing, coverage, access, and service provision of oral health care in 31 European countries. While most countries cover oral health care for vulnerable population groups, the level of statutory coverage varies widely across Europe resulting in different coverage and financing schemes for the adult population.

Health policy analysis on barriers and facilitators for better oral health in German care homes: a qualitative study.

OBJECTIVES: To assess possible health policy interventions derived from the theoretical domains framework (TDF) by studying barriers and facilitators on the delivery of oral healthcare and oral hygiene in German care homes using a behavioural change framework. DESIGN: Qualitative correlational study to evaluate a national intervention programme. SETTING: Primary healthcare in two care homes in rural Germany. PARTICIPANTS: Eleven stakeholders participating in the delivery of oral healthcare (hygiene, treatment) to older people, including two care home managers, four section managers, two nurses/carers and three dentists. INTERVENTIONS: Semistructured interviews conducted in person in the care homes or by phone. A questionnaire developed along the domains of the TDF and the Capabilities, Opportunities and Motivations influencing Behaviours model was used to guide the interviews. Interviews were transcribed and systematised using Mayring's content analysis along the TDF. RESULTS: 860 statements were collected. We identified 19 barriers, facilitators and conflicting themes related to capabilities, 34 to opportunities and 24 to motivation. The lack of access to professional dental care was confirmed by all stakeholders as a major limitation hampering better oral health. PRIMARY OUTCOME: A range of interventions can be discussed with the methodology we utilised. In our interviews, lack of dentists willing to treat patients at these facilities was the most discussed barrier for improving oral health of nursing home residents. SECONDARY OUTCOMES: Dentists highlighted the need for better incentives and facilities to deliver oral healthcare in these institutions. Differences with urban settings regarding access to healthcare were frequently discussed by our study participants. CONCLUSIONS: Within our sample, greater capacitation of care home staff, better financial incentives for dentists and increased cooperation between the two stakeholders should be considered when designing interventions to tackle oral health of care home residents in Germany.

Cost-effectiveness of Artificial Intelligence as a Decision-Support System Applied to the Detection and Grading of Melanoma, Dental Caries, and Diabetic Retinopathy.

Objective: To assess the cost-effectiveness of artificial intelligence (AI) for supporting clinicians in detecting and grading diseases in dermatology, dentistry, and ophthalmology. Importance: AI has been referred to as a facilitator for more precise, personalized, and safer health care, and AI algorithms have been reported to have diagnostic accuracies at or above the average physician in dermatology, dentistry, and ophthalmology. Design, Setting, and Participants: This economic evaluation analyzed data from 3 Markov models used in previous cost-effectiveness studies that were adapted to compare AI vs standard of care to detect melanoma on skin photographs, dental caries on radiographs, and diabetic retinopathy on retina fundus imaging. The general US and German population aged 50 and 12 years, respectively, as well as individuals with diabetes in Brazil aged 40 years were modeled over their lifetime. Monte Carlo microsimulations and sensitivity analyses were used to capture lifetime efficacy and costs. An annual cycle length was chosen. Data were analyzed between February 2021 and August 2021. Exposure: AI vs standard of care. Main Outcomes and Measures: Association of AI with tooth retention-years for dentistry and quality-adjusted life-years (QALYs) for individuals in dermatology and ophthalmology; diagnostic costs. Results: In 1000 microsimulations with 1000 random samples, AI as a diagnostic-support system showed limited cost-savings and gains in tooth retention-years and QALYs. In dermatology, AI showed mean costs of $750 (95% CI, $608-$970) and was associated with 86.5 QALYs (95% CI, 84.9-87.9 QALYs), while the control showed higher costs $759 (95% CI, $618-$970) with similar QALY outcome. In dentistry, AI accumulated costs of €320 (95% CI, €299-€341) (purchasing power parity [PPP] conversion, $429 [95% CI, $400-$458]) with 62.4 years per tooth retention (95% CI, 60.7-65.1 years). The control was associated with higher cost, €342 (95% CI, €318-€368) (PPP, $458; 95% CI, $426-$493) and fewer tooth retention-years (60.9 years; 95% CI, 60.5-63.1 years). In ophthalmology, AI accrued costs of R $1321 (95% CI, R $1283-R $1364) (PPP, $559; 95% CI, $543-$577) at 8.4 QALYs (95% CI, 8.0-8.7 QALYs), while the control was less expensive (R $1260; 95% CI, R $1222-R $1303) (PPP, $533; 95% CI, $517-$551) and associated with similar QALYs. Dominance in favor of AI was dependent on small differences in the fee paid for the service and the treatment assumed after diagnosis. The fee paid for AI was a factor in patient preferences in cost-effectiveness between strategies. Conclusions and Relevance: The findings of this study suggest that marginal improvements in diagnostic accuracy when using AI may translate into a marginal improvement in outcomes. The current evidence supporting AI as decision support from a cost-effectiveness perspective is limited; AI should be evaluated on a case-specific basis to capture not only differences in costs and payment mechanisms but also treatment after diagnosis.

Exploring variation of coverage and access to dental care for adults in 11 European countries: a vignette approach.

BACKGROUND: Oral health, coupled with rising awareness on the impact that limited dental care coverage has on oral health and general health and well-being, has received increased attention over the past few years. The purpose of the study was to compare the statutory coverage and access to dental care for adult services in 11 European countries using a vignette approach. METHODS: We used three patient vignettes to highlight the differences of the dimensions of coverage and access to dental care (coverage, cost-sharing and accessibility). The three vignettes describe typical care pathways for patients with the most common oral health conditions (caries, periodontal disease, edentulism). The vignettes were completed by health services researchers knowledgeable on dental care, dentists, or teams consisting of a health systems expert working together with dental specialists. RESULTS: Completed vignettes were received from 11 countries: Bulgaria, Estonia, France, Germany, Republic of Ireland (Ireland), Lithuania, the Netherlands, Poland, Portugal, Slovakia and Sweden. While emergency dental care, tooth extraction and restorative care for acute pain due to carious lesions are covered in most responding countries, root canal treatment, periodontal care and prosthetic restoration often require cost-sharing or are entirely excluded from the benefit basket. Regular dental visits are also limited to one visit per year in many countries. Beyond financial barriers due to out-of-pocket payments, patients may experience very different physical barriers to accessing dental care. The limited availability of contracted dentists (especially in rural areas) and the unequal distribution and lack of specialised dentists are major access barriers to public dental care. CONCLUSIONS: According to the results, statutory coverage of dental care varies across European countries, while access barriers are largely similar. Many dental services require substantial cost-sharing in most countries, leading to high out-of-pocket spending. Socioeconomic status is thus a main determinant for access to dental care, but other factors such as geography, age and comorbidities can also inhibit access and affect outcomes. Moreover, coverage in most oral health systems is targeted at treatment and less at preventative oral health care.

Interventions for treating cavitated or dentine carious lesions.

BACKGROUND: Traditionally, cavitated carious lesions and those extending into dentine have been treated by 'complete' removal of carious tissue, i.e. non-selective removal and conventional restoration (CR). Alternative strategies for managing cavitated or dentine carious lesions remove less or none of the carious tissue and include selective carious tissue removal (or selective excavation (SE)), stepwise carious tissue removal (SW), sealing carious lesions using sealant materials, sealing using preformed metal crowns (Hall Technique, HT), and non-restorative cavity control (NRCC). OBJECTIVES: To determine the comparative effectiveness of interventions (CR, SE, SW, sealing of carious lesions using sealant materials or preformed metal crowns (HT), or NRCC) to treat carious lesions conventionally considered to require restorations (cavitated or micro-cavitated lesions, or occlusal lesions that are clinically non-cavitated but clinically/radiographically extend into dentine) in primary or permanent teeth with vital (sensitive) pulps. SEARCH METHODS: An information specialist searched four bibliographic databases to 21 July 2020 and used additional search methods to identify published, unpublished and ongoing studies.  SELECTION CRITERIA: We included randomised clinical trials comparing different levels of carious tissue removal, as listed above, against each other, placebo, or no treatment. Participants had permanent or primary teeth (or both), and vital pulps (i.e. no irreversible pulpitis/pulp necrosis), and carious lesions conventionally considered to need a restoration (i.e. cavitated lesions, or non- or micro-cavitated lesions radiographically extending into dentine). The primary outcome was failure, a composite measure of pulp exposure, endodontic therapy, tooth extraction, and restorative complications (including resealing of sealed lesions). DATA COLLECTION AND ANALYSIS: Pairs of review authors independently screened search results, extracted data, and assessed the risk of bias in the studies and the overall certainty of the evidence using GRADE criteria. We measured treatment effects through analysing dichotomous outcomes (presence/absence of complications) and expressing them as odds ratios (OR) with 95% confidence intervals (CI). For failure in the subgroup of deep lesions, we used network meta-analysis to assess and rank the relative effectiveness of different interventions. MAIN RESULTS: We included 27 studies with 3350 participants and 4195 teeth/lesions, which were conducted in 11 countries and published between 1977 and 2020. Twenty-four studies used a parallel-group design and three were split-mouth. Two studies included adults only, 20 included children/adolescents only and five included both. Ten studies evaluated permanent teeth, 16 evaluated primary teeth and one evaluated both. Three studies treated non-cavitated lesions; 12 treated cavitated, deep lesions, and 12 treated cavitated but not deep lesions or lesions of varying depth.  Seventeen studies compared conventional treatment (CR) with a less invasive treatment: SE (8), SW (4), two HT (2), sealing with sealant materials (4) and NRCC (1). Other comparisons were: SE versus HT (2); SE versus SW (4); SE versus sealing  with sealant materials (2); sealant materials versus no sealing (2).  Follow-up times varied from no follow-up (pulp exposure during treatment) to 120 months, the most common being 12 to 24 months. All studies were at overall high risk of bias. Effect of interventions Sealing using sealants versus other interventions for non-cavitated or cavitated but not deep lesions There was insufficient evidence of a difference between sealing with sealants and CR (OR 5.00, 95% CI 0.51 to 49.27; 1 study, 41 teeth, permanent teeth, cavitated), sealing versus SE (OR 3.11, 95% CI 0.11 to 85.52; 2 studies, 82 primary teeth, cavitated) or sealing versus no treatment (OR 0.05, 95% CI 0.00 to 2.71; 2 studies, 103 permanent teeth, non-cavitated), but we assessed all as very low-certainty evidence. HT, CR, SE, NRCC for cavitated, but not deep lesions in primary teeth The odds of failure may be higher for CR than HT (OR 8.35, 95% CI 3.73 to 18.68; 2 studies, 249 teeth; low-certainty evidence) and lower for HT than NRCC (OR 0.19, 95% CI 0.05 to 0.74; 1 study, 84 teeth, very low-certainty evidence). There was insufficient evidence of a difference between SE versus HT (OR 8.94, 95% CI 0.57 to 139.67; 2 studies, 586 teeth) or CR versus NRCC (OR 1.16, 95% CI 0.50 to 2.71; 1 study, 102 teeth), both very low-certainty evidence. CR, SE, SW for deep lesions The odds of failure were higher for CR than SW in permanent teeth (OR 2.06, 95% CI 1.34 to 3.17; 3 studies, 398 teeth; moderate-certainty evidence), but not primary teeth (OR 2.43, 95% CI 0.65 to 9.12; 1 study, 63 teeth; very low-certainty evidence). The odds of failure may be higher for CR than SE in permanent teeth (OR 11.32, 95% CI 1.97 to 65.02; 2 studies, 179 teeth) and primary teeth (OR 4.43, 95% CI 1.04 to 18.77; 4 studies, 265 teeth), both very low-certainty evidence. Notably, two studies compared CR versus SE in cavitated, but not deep lesions, with insufficient evidence of a difference in outcome (OR 0.62, 95% CI 0.21 to 1.88; 204 teeth; very low-certainty evidence). The odds of failure were higher for SW than SE in permanent teeth (OR 2.25, 95% CI 1.33 to 3.82; 3 studies, 371 teeth; moderate-certainty evidence), but not primary teeth (OR 2.05, 95% CI 0.49 to 8.62; 2 studies, 126 teeth; very low-certainty evidence). For deep lesions, a network meta-analysis showed the probability of failure to be greatest for CR compared with SE, SW and HT. AUTHORS' CONCLUSIONS: Compared with CR, there were lower numbers of failures with HT and SE in the primary dentition, and with SE and SW in the permanent dentition. Most studies showed high risk of bias and limited precision of estimates due to small sample size and typically limited numbers of failures, resulting in assessments of low or very low certainty of evidence for most comparisons.

Dental service utilization in the very old: an insurance database analysis from northeast Germany.

OBJECTIVES: We assessed dental service utilization in very old Germans. METHODS: A comprehensive sample of 404,610 very old (≥ 75 years), insured at a large statutory insurer (Allgemeine Ortskrankenkasse Nordost, active in the federal states Berlin, Brandenburg, Mecklenburg-Western Pomerania), was followed over 6 years (2012-2017). Our outcome was the utilization of dental services, in total (any utilization) and in five subgroups: (1) examinations and associated assessment or advice, (2) restorations, (3) surgery, (4) prevention, (5) outreach care. Association of utilization with (1) sex, (2) age, (3) region, (4) social hardship status, (5) ICD-10 diagnoses, and (6) German modified diagnosis-related groups (GM-DRGs) was explored. RESULTS: The mean (SD) age of the sample was 81.9 (5.4) years. The utilization of any dental service was 73%; utilization was highest for examinations (68%), followed by prevention (44%), surgery (33%), restorations (32%), and outreach care (13%). Utilization decreased with age for nearly all services except outreach care. Service utilization was significantly higher in Berlin and most cities compared with rural municipalities, and in individuals with common, less severe, and short-term conditions compared with life-threatening and long-term conditions. In multi-variable analysis, social hardship status (OR: 1.14; 95% CI: 1.12-1.16), federal state (Brandenburg 0.85; 0.84-0.87; Mecklenburg-Western Pomerania: 0.80; 0.78-0.82), and age significantly affected utilization (0.95; 0.95-0.95/year), together with a range of co-morbidities according to ICD-10 and DRG. CONCLUSIONS: Social, demographic, regional, and general health aspects were associated with the utilization of dental services in very old Germans. Policies to maintain access to services up to high age are needed. CLINICAL SIGNIFICANCE: The utilization of dental services in the very old in northeast Germany showed significant disparities within populations. Policies to allow service utilization for sick, economically disadvantaged, rural and very old populations are required. These may include incentives for outreach servicing, treatment-fee increases for specific populations, or referral schemes between general medical practitioners and dentists.

Interventions to improve oral health of older people: A scoping review.

OBJECTIVES: A range of interventions have been tested to improve oral health of older people. We performed a scoping review to map interventions' aims, outcome measures and findings, and to locate them on different levels of care. DATA: We systematically screened for (1) controlled studies on (2) people over 65 years of age, (3) comparing at least two interventions to improve oral health. Interventions were summarized according to their aims and the employed intervention type, mapped on their level of action, and classified as primary/secondary/tertiary prevention. SOURCES: Studies retrieved via MEDLINE, EMBASE, CINAHL. STUDY SELECTION: Eighty-one studies (published 1997-2019, conducted mainly in high-income countries) were included. Sample sizes varied (n = 24-1987). Follow-up was 0.25-60 months. Most studies (64/81) found a statistically significant benefit of the intervention. A total of 13 different aims were identified, and a range of intervention types employed (e.g. educational interventions, professional oral healthcare, restorative treatment, fluoride application and, generally, dentifrices, mouthwashes, chewing gums/food supplements). Most studies were located on the carer/patient level (56/81 studies) or the system/policy-maker level (44/81). The majority of studies aimed for primary prevention (64/81). CONCLUSIONS: Oral health improvement interventions are widely studied. However, study aims, methods and outcome measures are highly heterogeneous, which limits the ability for robust conclusions. Current research focusses on primary prevention on the level of patients/carers or system/policy-maker level. Future studies may want to consider interventions on dentists' level focussing on secondary prevention. These studies should rely on a core set of comprehensive, standardized set of outcome measures. CLINICAL SIGNIFICANCE: While specific interventions seem efficacious to improve older people's oral health, the current body of evidence is neither comprehensive (significant gaps exists in relevant levels of the care process) nor comparable enough to draw robust conclusions.