A study on moral hazard in dentistry: costs of care in the private and the public sector

Tuominen R, Eriksson A‐L. A study on moral hazard in dentistry: costs of care in the private and the public sector. Community Dent Oral Epidemiol 2011; 39: 458–464. © 2011 John Wiley & Sons A/S Abstract – Objectives: The aim of this study was to evaluate the costs of subsidized care for an adult population provided by private and public sector dentists. Methods: A sample of 210 patients was drawn systematically from the waiting list for nonemergency dental treatment in the city of Turku. Questionnaire data covering sociodemographic background, dental care utilization and marginal time cost estimates were combined with data from patient registers on treatment given. Information was available on 104 patients (52 from each of the public and the private sectors). Results: The overall time taken to provide treatment was 181 days in the public sector and 80 days in the private sector (P < 0.002). On average, public sector patients had significantly (P < 0.01) more dental visits (5.33) than private sector patients (3.47), which caused higher visiting fees. In addition, patients in the public sector also had higher other out‐of‐pocket costs than in the private sector. Those who needed emergency dental treatment during the waiting time for comprehensive care had significantly more costly treatment and higher total costs than the other patients. Overall time required for dental visits significantly increased total costs. The total cost of dental care in the public sector was slightly higher (P < 0.05) than in the private sector. Conclusions: There is no direct evidence of moral hazard on the provider side from this study. The observed cost differences between the two sectors may indicate that private practitioners could manage their publicly funded patients more quickly than their private paying patients. On the other hand, private dentists providing more treatment per visit could be explained by private dentists providing more than is needed by increasing the content per visit.     

Socioeconomic and clinical factors associated with caregivers' perceptions of children's oral health in Brazil

Piovesan C, Marquezan M, Kramer PF, Bönecker M, Ardenghi TM. Socioeconomic and clinical factors associated with caregivers’ perceptions of children’s oral health in Brazil. Community Dent Oral Epidemiol 2011; 39: 260–267. © 2010 John Wiley & Sons A/S Abstract – Objectives: We assessed how socioeconomic and clinical conditions could affect parents’ perceptions of their child’s oral health. Methods: A cross‐sectional study was conducted in a sample of 455 children, aged 1–5 years, representative of Santa Maria, a southern city in Brazil. Participants were randomly selected among children attending a National Day of Children’s Vaccination. Clinical examinations provided information on the prevalence of caries, dental trauma, and occlusion. The caregivers’ perception of children’s oral health and socioeconomic status were assessed by means of a questionnaire. A Poisson regression model using robust variance (Prevalence ratio: PR; 95% CI, P ≤ 0.05) was performed to assess the association between the predictor variables and outcomes. Results: Parents were more likely to rate their child’s oral health as ‘poor’ if the former earned a lower income and the latter had anterior open bite and dental caries. Parents of black children with anterior open bite and dental caries were more likely to rate their child’s oral health as ‘worse than that of other children’. Conclusions: Clinical and socioeconomic characteristics are significantly associated with parents’ perceptions of their child’s oral health. Understanding the caregivers’ perceptions of children’s oral health and the factors affecting this could be useful in the planning of public health polices, in view of the inequity in the oral health pattern.     

Patient satisfaction with emergency oral health care in rural Tanzania

Emergency oral health care, as conceived in Tanzania, is an on-demand service provided at a rural health center or dispensary by a Rural Medical Aide. The service includes: simple tooth extraction under local anesthesia, draining of abscesses, control of acute oral infection with appropriate drug therapy, first aid for maxillo-facial trauma, and recognition of oral conditions requiring patient referral for further care at the district or regional hospital dental clinic. The objective of the present study was to describe patient satisfaction with emergency oral health care services in rural Tanzania and determine the relative importance of factors influencing patient satisfaction. The study was carried out as a cross-sectional interview survey between April 1993 and May 1994 using a patient satisfaction questionnaire in rural villages in the Rungwe district of Tanzania. It included 206 patients aged 18 years or more who had received emergency oral health care between April 1993 and March 1994. Overall, 92.7% of the respondents re-ported that they were satisfied with the service. Patients who were married, had no formal education and lived more than 3 km from the dispensary were more likely to be satisfied with treatment. In a logistic regression model, a good working atmosphere at the dispensary, a good relationship between care provider and patients (art of care) and absence of post-treatment complications significantly influenced patient satisfaction with odds ratios of 10.3, 17.4 and 6.2, respectively.     

CONFERENCE PRESENTATION:Changing perceptions of oral health and its importance to general health: provider perceptions, public perceptions, policyma ker perceptions

He first ever Surgeon General's Report on Oral Health¹ emphasizes that oral health is essential to the general health and well‐being of all Americans, and that oral health can be achieved. But it will require that we think about and approach oral health activities in a different manner. If we desire to influence the mind‐set of health care providers, the public, policymakers, and institutions, how do we get from what we know about the relationship of oral health and general health to integrating the notion into everyday actions? The Surgeon General's Report on Oral Health has elevated this issue to the forefront of health care and provided us with an extraordinary opportunity. The challenge: Lead with action and catalyze integration into multiple forum‐public, private, and professional‐and engage in activities that will change how oral health is perceived broadly. Ultimately, geriatric oral health and the health of all access‐limited populations should benefit. To continue preserving the oral health of the millions of older individuals who now enjoy it and to ensure it for those who lack it will require change on multiple societal levels: the health care providers, the neighborhood, the community; Federal, state, and local governments; and the nation as a whole. It means addressing and overcoming multiple barriers to oral health care, which may include problems or disparities in: education, economics, the environment, cultural and social issues, and the health care system itself¹ To change perceptions, we must remove the barriers to care, educate the stakeholders who can influence or benefit from training programs, conduct broader, population‐based research, build public and private partnerships, develop a stronger health care infrastructure, and expand initiatives that target specific risks for declining oral health. In addition to seeking new answers to these problems, it is imperative that we apply what we already know.     

Oral hygiene knowledge of high-risk Grade One children: an evaluation of two methods of dental health education

Abstract – The effectiveness of two methods of dental health education (DHE) for improving oral hygiene knowledge among high‐risk Grade One students was evaluated. Fifty elementary schools in the former City of North York, Canada were assigned to one of two groups. In one group, students received a classroom‐based DHE lesson which was reinforced by two small‐group sessions (n=243). In the other group, students received only a single classroom‐based DHE lesson (n=206). After DHE interventions, students in both groups displayed improved knowledge for most oral hygiene questions (e.g., when should you throw your toothbrush away?). However, for several questions, a significantly higher proportion of “classroom plus small‐group sessions” students displayed improved knowledge compared to students receiving only a classroom lesson. These items included: awareness that cavity prevention and removal of germs are two purposes of oral hygiene; and knowledge that teeth help people to eat and talk. Results suggest a classroom‐based lesson combined with small‐group sessions is a more effective method of improving oral hygiene knowledge among high‐risk Grade One students compared to a single classroom‐based lesson.     

The efficiency of the community dental service in England: a data envelopment analysis

OBJECTIVES: To assess the efficiency with which health authorities' Community Dental Services provide dental care in England. METHODS: A data envelopment analysis of inputs (hours worked by dental officers, therapists, hygienists and others) and outputs (screening, treatment, prevention) of the Community Dental Service (CDS) was conducted. Relative efficiency ratings of the CDS by health authority were further analysed in order to identify external factors which effect efficiency and are outside the control of the Community Dental Service. RESULTS: The relative efficiency of the CDS varies widely in England--on average the CDS is operating at 75% of efficient levels compared to best-practice services. This could not be explained by plausible factors outside the CDS's control, such as differences in deprivation and urban-rural differences between health authorities. CONCLUSIONS: These results, if validated by further studies, should be disturbing since many Community Dental Services services appear to be under-performing. However, this data-driven study could not uncover the detailed context of an individual service's performance. A useful next step would be detailed case-studies of several "star" and under-performing services to search for deeper reasons underpinning relative performance levels.     

Developing management information from an administrative database of dental services: identifying factors that influence costs

OBJECTIVE: We describe service patterns and compare changes in program expenditures with the Consumer Price Index over eight years in a dental program with a controlled-fee schedule offered to Canadian First Nations and Inuit people. METHODS: We obtained the computerized records of dental services for the period from 1994 to 2001. Each record identified the date and type of service, region and type of provider, age of the client and encrypted identifying information on clients, bands, and providers. We classified the individual services into related types (diagnostic, preventive, etc.). We aggregated the records by client and developed indices for the numbers of clients, mean numbers of services per client, cost per service, and prices. FINDINGS: Over the 8 years, 16.0 million procedures, totaling 811.8 million dollars, were provided to 538,034 different individuals, approximately 76% of the eligible population. Restorative procedures accounted for 36% of all expenditures followed by diagnostic (12.7%), preventive (12.2%), and orthodontic (8.9%) services. For much of the period, increases in program expenditures were exceeded by increases in the Consumer Price Index. This was consistent with fewer services per client, a less expensive mix of services, and relatively flat prices. However, in 2000 and 2001 higher prices and more clients resulted in increasing expenditures. CONCLUSIONS: Program expenditures were influenced by different factors over the study period. In the final two years, increasing expenditures were driven by price increases and increasing numbers of clients, but not by increasing numbers of services per client, nor a 'richer' mix of services.     

First‐year oral health and dentistry student perceptions of future professional work

Objectives: To explore and compare how pre‐doctoral dentistry (BDS) and oral health (BOH) students characterise their future professional work at the start and end of their first‐year professional programme. Materials and methods: All BDS and BOH students were given an anonymous survey on the first and last days of their 2009 course. Start and end surveys (ES) were completed by 75% of BDS (51) and 83% of BOH students (33). This paper examines students’ responses to two questions asking them to identify a situation characterising their future professional work and a professional difficulty they would likely encounter. Student responses were analysed inductively to identify key themes and confirm each theme’s ‘weighting’ based on frequency of mention. Results: Students’ answers to both questions revealed eight characterisations of future professional work involving the following: restorative tasks, patient‐related concerns, patient emotion and behaviour, population‐level/public health concerns, disease prevention and monitoring, communication, teamwork and self‐management. In ES responses, BDS students emphasised restorative tasks as central to a dentist’s work, and in both surveys perceived ‘dealing with patients’ as a central difficulty. In contrast, BOH students’ answers to both questions revealed a patient care emphasis, and in both surveys, BOH students emphasised patient‐related concerns as a likely difficulty. Conclusion: Bachelor of Dentistry students characterised their work as primarily interventive, and BOH students, as primarily patient‐centred, communicative, and preventive. Whilst BDS students apparently valued restorative capabilities, BOH students valued the ability to ensure patient well‐being. Further research will examine students’ differing perceptions and how these change over time.     

An analysis examining socio-economic variations in the provision of NHS general dental practitioner care under a fee for service contract among adolescents: Northern Ireland Longitudinal Study

Telford C, Murray L, Donaldson M, O’Neill C. An analysis examining socio‐economic variations in the provision of NHS general dental practitioner care under a fee for service contract among adolescents: Northern Ireland Longitudinal Study. Community Dent Oral Epidemiol 2012; 40: 70–79. © 2011 John Wiley & Sons A/S Abstract – Objectives: To examine socio‐economic variations in the use of publicly funded general dental practitioner care by adolescents under a fee for service arrangement. Method: Publicly funded general practitioner reimbursement data were linked to census and vital statistics data within the Northern Ireland Longitudinal Study. Data relate to 12 846 adolescents aged 11 or 12 in April 2003 included within the Northern Ireland Longitudinal Study (28% of the population). The main outcome measure was consumption of dental care between 2003/2004 and 2007/2008 by socio‐economic status (as measured by National Statistics Socio‐economic Classification of occupation and highest educational attainment of household reference person). Results: In multivariate analysis, socio‐economic status was a significant determinant of dental care consumed. Those of the lowest socio‐economic status, according to both occupation and highest educational attainment of household reference person, were less likely to have consumed orthodontics OR 0.76 (0.62, 0.95) and OR 0.79 (0.69, 0.91), respectively. Those of lower socio‐economic status were, however, more likely to have undergone an extraction and restorative treatment and also consumed on average more treatment than those of higher socio‐economic status. Conclusion: A demand‐led service, in which practitioners are reimbursed in part on a fee for service basis, may create incentives that contribute to different patterns of utilization between social groups. Such a system may not be providing equal access for equal need and may widen existing socio‐economic disparities in oral health among adolescents.     

A comparison of the costs and patient acceptability of professionally applied topical fluoride foam and varnish

OBJECTIVES: In Canada and the United States, professionally applied topical fluorides (PATF) are usually applied as a gel or foam. However, fluoride varnish has also been found to be effective for caries prevention and may be a preferred method because less time is required and fluoride exposure can be better controlled. The goal of this study was to compare the costs and patient acceptability of two methods of PATF (foam and varnish). METHODS: The study population was a convenience sample of high-risk children from the York Region and the city of Hamilton, Ontario, Canada, who had been identified as requiring fluoride therapy (n = 256). Children received from dental hygienists either fluoride foam applied in trays or fluoride varnish painted on tooth surfaces. An observer recorded the time to perform each procedure, adverse outcomes, and the satisfaction of children with treatment. RESULTS: The varnish technique took significantly less time compared to foam (5.81 vs 7.86 minutes; P < .0001). Significant differences between procedure times were found in all age groups, but the largest difference was for children aged 3-6 years (5.22 vs 8.61 minutes; P < .0001). Signs of gagging were observed in a lower proportion of participants who received varnish (3.8% vs 15.1%; P < .01), and this difference was largest for children aged 3-6 years (2.6% vs 29.7%; P < .01). The cost per varnish application, for children aged 3-6 years, was substantially less after labor costs were considered (dollar 3.43 vs dollar 4.43, CDN). CONCLUSIONS: Varnish applications were found to take less time and resulted in fewer signs of discomfort. These results support the use of fluoride varnish in caries prevention programs, especially for younger children.     

心理健康教育对上颌赝复体修复疗效的影响

目的评价心理健康教育对上颌骨缺损赝复体修复效果的影响。方法选择46例赝复体修复患者,随机平分为试验组和对照组。试验组在赝复体修复前后进行系统的心理健康教育,对照组则按照常规诊疗方法进行。比较两组患者戴用赝复体后1、3月时的满意度调查结果。结果试验组在咀嚼功能、语音功能、舒适性、吞咽流畅度方面满意度高于对照组,其差异具有统计学意义(P<0.05)。结论在赝复体修复过程中,心理健康教育可明显提高其修复效果。     

Effect of time costs on demand for dental services among adults in Norway in 1975 and 1985

The aim of the present study was to assess the effect of travel time, time spent on a waiting list and time spent in the waiting room on demand for dental services in Norway. The analysis was performed on two sets of national data from 1975 and 1985, and on one set of local data from 1987. The national data were representative of the non-institutionalized Norwegian population aged 20 yr and above. Travel time had an effect on demand in 1975, but not in 1985. Time spent on a waiting list had no opportunity cost, and did not influence demand. There was a statistically significant association between time spent in the waiting room and demand. However, this association disappeared when the effect of dental attendance pattern was controlled for. Regular attenders had shorter waiting times than those who were irregular attenders. This study has shown that factors such as presence of teeth, family income, and age are more important than travel time on demand for dental services.