In addition to understanding the effectiveness of interventions to prevent and control oral disease, health providers, payers, and policymakers need reliable information about intervention costs and cost-effectiveness (CE) if they are to make informed decisions about allocating resources. With health-care costs increasing rapidly, translation of interventions documented to be effective in research settings may be limited if reliable and accurate estimates of costs and CE are not available. Although the CE of community water fluoridation and dental sealants has been documented (1-9), and CE research on dental procedures in clinical settings is growing (10-15), research on the CE of interventions implemented to improve oral health knowledge, attitudes, and behaviors is limited. Because health behaviors and lifestyle influence oral health and long-term health, and have economic and social consequences, it is important to identify effective and cost-effective behavioral interventions to promote oral health and to reduce documented oral health disparities (16).
Economic analyses may vary with regard to types of costs measured, how costs are determined, methods employed to assess potential intervention savings, and documentation. This variability may reflect differences in resources allocated to cost analyses, or unfamiliarity with methods employed in conducting such studies, as there are few such studies of behavioral interventions implemented to improve oral health. The Guide to Community Preventive Services (17) typically conducts systematic reviews of the CE of an intervention after the effectiveness of the intervention has been established. Synthesizing CE ratios has been proven problematic because methods and reporting may vary across studies (18). Conducting the economic analysis while studying the effectiveness of the intervention may encourage the use of established protocols consistent with the recommendations of the Panel of Cost-Effectiveness in Health and Medicine (Panel) (19); in turn, such practices could improve the quality and uniformity of economic analyses (18,20). The findings may be used for dissemination and translation of effective interventions and may contribute to the understanding of factors influencing intervention effectiveness, CE, and components that may be altered to improve both.
This paper provides an overview of strategies for conducting economic evaluations of behavioral interventions for oral health promotion and disease prevention. Because it will not be possible to address every aspect of this topic or to provide detailed case studies, we reference books on economic analyses of health interventions (19,21-26). As this paper is structured to provide a framework for readers who may have little familiarity with economic analyses, the section Overview of economic terminology presents key concepts, including an overview of four types of economic analyses. The section Factors that influence the study design describes factors that influence the study design. Then we follow a project lifecycle and examine issues related to research design in the section Research design; a discussion of methods follows in the section Discussion. The section Research design includes information on measures, data collection, and data analysis. To illustrate the described research methods, we refer to selected studies in the analysis section. These studies include behavioral interventions addressing oral health in clinical and nonclinical settings (27-31) and two studies, one of community water fluoridation programs (CWFP) (2) and another of school-based dental sealant programs (SBSP) (5), that do not focus on behavior change yet include strategies for assessing oral health costs and savings (see Table 1).
|Author and year||Grant et al. 2007 (30)||Wennhall et al., 2008 and 2010 (29,53)||Kobayashi et al., 2005 (27)||O'Connell et al., 2005 (2)||Scherrer et al., 2007 (5)||Hietasalo et al., 2009 (31)||Kowash et al., 2006 (28)|
|Type of study||Observational||Observational||Observational||Decision cost model||Decision cost model||Randomized clinical trial||Randomized clinical trial|
|Intervention||Intervention: Parent oral health counseling, child dental screening and fluoride varnish application||Intervention: Comprehensive oral health outreach and preventive program that included education on diet and oral hygiene, Comparison: Care as usual (historic reference group)||Intervention: Community-based program included community outreach, parent and dental professional education, child referrals for services, preventive and treatment services, and higher reimbursement for trained dentists; Comparison: Usual care||Intervention: Community water fluoridation programs, Comparison: No program||Intervention: School-based dental sealant programs, Comparison: no program||Experimental group: Patient-centered education on oral hygiene and nutrition, preventive services, clinical exams, and referrals for treatment; children averaged 3-4 visits over a 12-month period, community and school oral health promotion; Control group: Usual care, community and school oral health promotion||Experimental group: Health educators provided education on oral hygiene and nutrition and dental screenings during home visits conducted at varying frequency (Groups A-D); Control group: Usual care|
|Location||North Carolina, United States||Malmo, Sweden||State of Washington, United States||Colorado, United States||7 states in the United States||Pori, Finland||Leeds, United Kingdom|
|Setting||University pediatric clinic||Outreach facility||Community||Community||Schools||Public dental clinics||Home-based|
|Target population||Children aged 6-36 months, Intervention group n = 665||High-risk children living in a low-socioeconomic multicultural area, Intervention group: Children aged 2 years n = 651, Historic controls n = 201||Children aged 6 years and younger, Intervention group: children in the intervention county (approximately 20,000 served 1997-1999), Comparison group: children in a county without the intervention||Persons age 5 years and older||Children 7-9 years old (children in second grade)||Children ages 11-12 years with at least one active initial caries lesion, Experimental group n = 250, Control group n = 247||Mothers of infants age 8 months living in a low-socioeconomic area with high caries prevalence, Intervention group n = 228 children, Control group n = 55 children|
|Health outcome||Not provided||Oral health status of children age 5 years, Intervention group: 8.2 DEFS, Reference group: 11.2 DEFS||Oral health status of children in third grade in each county in 2002 (n = 453), Intervention county: ratio of DFS to all erupted surfaces: 0.1, Comparison county ratio: 0.2||CWFPs reduced the decay increment by approximately 25%||Averted caries estimated from an annual DMFT attack rate of 0.132 over the 9 year period, adjusted for the annual sealant retention rate of 90%||Experimental group: 2.56 DMFS, Control group: 4.60 DMFS, Incremental effectiveness: 2.04 averted DMFS (CI: 1.26-2.82)||Intervention groups: 0.29 DMFS for Group A, 0 DMFS for Groups B-D, 3% of children in Groups A-D had gingivitis; Control group: 1.75 DMFS, 16% had gingivitis|
|Time frame and analytic horizon||Time frame and analytic horizon: 31 months (12/2001-7/2004)||Time frame and analytic horizon: 3 years (1998-2000)||Time frame and analytic horizon: 7 years (1995-2001)||Time frame: 1 year, Analytic Horizon: Lifetime||Time frame: 1 year, Analytic Horizon: 9 years||Time frame and analytic horizon: 3.4 years (2001-2005)||Time frame and analytic horizon: 3 years, participants recruited in 1995|
|Perspective||Health-care provider||Health provider, health payer (government)||Health-care provider, health payer||Society||Health-care provider, health payer (government), society||Health-care provider, health payer (government)||Health-care provider, health payer (government)|
|Economic outcomes||Intervention costs: $4,951, reimbursement for intervention services: $51,992, net program costs: −$47,041||Intervention cost per child: €310, Net cost per child including treatment revenue: €30 (CI: €109 to −61 (cost savings))||Mean annual intervention costs per child for birth cohort (born in 1994 or 1995): $5.33, Mean annual Medicaid dental expenditures for birth cohort: intervention county −$207 and comparison county −$199, Mean annual net costs of health-care provider and Medicaid: $13.50||Annual net costs $148.9 million (CR: $115.1-187.2 million), net costs per person $60.78 (CR: $46.97-76.41)||Results for Wisconsin: Health-care provider cost per child sealed $20.51, Annual state net cost savings (includes Medicaid/SCHIP reimbursement) −$55,290, Annual societal net cost savings: $295,421-393,628||Experimental group cost per child: €496.45, Control group cost per child: €426.95, Incremental cost per child: €69.50 (CR: 28.25-110.75), Incremental cost-effectiveness: €34.07 per averted DMFS||Annual cost estimates for a steady-state year: intervention costs: £6,445, Intervention savings: £36,386, Benefit-cost (intervention costs/savings) ratio: 5.6, Intervention costs per averted DMFS: £1.8|
|Measurement of intervention costs||Micro-costing: Obtained intervention costs related to labor and dental supplies from a retrospective chart audit of encounter forms to obtain clinical and financial (reimbursement) data||Micro-costing: Obtained prevention and treatment service costs for rental facilities, equipment, and supplies; personnel costs were estimated based on dental procedure data, salaries, and estimates for program management; overhead costs estimated to be 50% of salaries||Micro-costing: Obtained intervention costs for dental professional training and community outreach and marketing; Cost estimates for preventive and treatment services and increased Medicaid reimbursement for trained providers obtained from Medicaid administrative records for birth cohort||Gross-costing: Used published results on program costs and state data on water system fluoride levels and population size||Gross-costing: Used published data and data obtained from data on sealant program utilization and costs (e.g., screening rates, direct and indirect costs of labor, equipment, dental supplies, and travel), used published information for 4 states and conducted interviews with personnel in 3 other states, excluded administrative costs||Micro-costing: Assessed intervention costs and dental treatment costs; costs for labor (salaries and benefits), dental supplies, capital equipment, and overhead were included; costs allocated to services based on assigned treatment weights; costs of community health promotion excluded||Micro-costing: Assessed intervention costs for labor (salaries), dental and education supplies, and travel|
|Measurement of intervention savings||Not addressed||The methodology described above included costs for treatment services.* Additional information obtained to estimate revenue for avoided treatment||The methodology described above included costs for treatment services. Thus, no additional data collection was conducted*||Gross-costing: Published results and findings from secondary data analysis were used to estimate averted treatment costs for applying and maintaining a restoration (e.g., single-surface amalgam, multi-surface resin-based composite, crown) over a lifetime, household direct and indirect costs related to time and travel were included||Gross-costing: Published results used to estimate averted treatment costs over the average sealant life (9 years) based on use of a single surface amalgam or resin-based composite restoration, household direct and indirect costs related to time and travel were included||The methodology described above included costs for treatment services. Thus, no additional data collection was conducted*||Averted treatment costs were estimated from child DMFS results, assumptions concerning treatment, and published fees for dental procedures|
|Base year and currency||US dollar||2008, Euro||1995, US dollar||2003, US dollar||2003-2004 academic year, US dollar||2004, Euro||Pound†|
|Discount rate||Not employed||3%||Not employed||3%||3%||Not employed||Not employed|
|Decision analysis and/or probabilistic sensitivity analysis software||Not employed||Not employed||Not employed||TreeAge Pro 2005||AutoMod 12.0||R version 2.8.1||Not employed|
This overview aims to provide information both for those planning and conducting such studies and for experts in health planning and policy who would like an improved understanding of economic findings reported in published studies. The approaches described in this paper may also be used in studies of other oral health interventions and of health policy and reimbursement changes that influence the provision of oral health, as well as for program management, to clarify the impact of existing or planned resource allocations.