4. Introduction
Need for economic evaluation
Types of economic evaluations
Cost-minimization analysis
Cost-effectiveness analysis
Cost-utility analysis
Cost-benefit analysis
Stages of economic evaluation
Limitations of economic evaluation
5. Economic considerations of
- Pit and fissure sealants
- Community water fluoridation
- Fluoridated dentifrices
- Professionally applied topical fluorides
- Fluoride Mouth rinsing programs
- Fluoride supplements
Conclusions
References
6. ‘We never will have all we need. Expectation will always
exceed capacity . . This service must always be
changing, growing and improving, it must always appear
inadequate.’
ANEURYN BEVIN, 1948
7. Changes in the age structure
Increasing real incomes
Improvements in medical technology
8. The other side of the scarcity equation relates to the
finite nature of resources.
The term ‘resources’ covers all inputs used to produce
goods and services.
9. 1. land - the physical resources of the planet including
mineral deposits
2. labour - human resources in the sense of people as
workers
3. capital - resources created by humans to aid production,
such as tools, machinery and factories
4. enterprise - the human resource of organising the other
three factors to produce goods and services.
10. The Utilitarian Theory
Healthcare should be distributed so as to maximise the
health of society (eg increase life expectancy; reduce
infant mortality) without regard to how that good is
actually distributed.
11. The Egalitarian Theory
- everyone has a claim to the amount of healthcare
resources which gives them a level of health equal to
that of others.
The Rawlsian Theory
-that each person has an equal right to the system and
when making social and economic choices, those who
are least advantaged should have maximum benefit.
12. Samuelson, defined economics as:
“The study of how men and society end up choosing,
with or without the use of money, to employ scarce
productive resources that could have alternative uses, to
produce various commodities and distribute them for
consumption, now or in the future, among various
people and groups in society. It analyses the costs and
benefits of improving patterns of resource allocation.”7
13. “the study of choice”
“the study of resource use”
“the science of scarcity ”
“the dismal science”
It is because of resource scarcity that we have to make
choices about different ways of using resources.
Aim-to determine how resources can give the greatest
benefit.
14. Health economics
‘the application of the theories, concepts and techniques
of economics to the health sector’.
Health care
“all types of services rendered by professionals or para-
professionals which have a bearing on the health status
of an individual or entire population of a country”.
15. The comparative analysis of alternative course of actions
in terms of both their costs and consequences.
-Drummond 1987
Cunningham S. Economic evaluation of health care-is it important to us?British
Dent J 2000;188;150-6.
16. Inputs/Cost
Direct costs-salaries
of health care
peronnels/direct
medical costs
Indirect costs/production
losses-travelling costs,loss
of time from work
Intangible cost-Pain and
sufferning.sociodental
indicators
Outcome/Consequences
Direct-health benefits
Indirect- production
gains
Natural units -tooth surface
savedMonetary units
Utility measures-life years
gained weighed by the values
people place on different
states of health
17. the allocation of resources between various health
promoting activities
the quantity of resources used in health services
delivery
the organization and funding of health service
institutions
the efficiency with which resources are allocated and
used for health purposes
the effects of preventive, curative and rehabilitative
health services on individuals and society.
18. Assist decision making, usually in the health care
sector, to promote efficiency and equity.
Health and health care resource use; introducing a
thought process that recognizes scarcity, the need to
make choices and, thus, that more is not always better if
other things can be done with the same resources.
Health economics is about maximizing social benefits
obtained from constrained health producing resources.
20. Used when the health consequence associated with
each program are equivalent.
E.g.. sealants placed by dental auxiliaries and dentist
are equally effective.
-Identify the least expensive strategy to attain the
desired outcome.
unit of measurement is cost per intervention.
21. Commonly used method in health economics.
Cost-effectiveness analysis is used to compare
alternative programs with the same health goal.
A program is cost effective if:
Less costly and at least as effective
Costly, but the benefits worth the additional costs
22. Given that it has been decided that- “this type of health
care will be provided, what is the best way of doing so?’
the aim is to find the most efficient treatment option in
terms of cost per unit effect (eg cost per tooth year
gained).
Disadvantage
it cannot be used to to compare interventions which
have several different clinical effects
27. Utility refers to the value or worth of a particular health
state or an improvement in that health state.
Utility values lie between 0 and 1, where 0 is equivalent
to death and 1 is equivalent to perfect health.
Cohen and Jargo (1976)- that the greatest contribution
of dentistry is the improvement of quality of life through
the prevention and treatment of oral disease.
28. QALY-measures the quality of life generated by health
care interventions.
1 year of perfect health=1 QALY
1 year of less than perfect health=<1.
CUA should be the method of choice when quality of life
is an important outcome.
29. 1) Define the health intervention and specify the
perspectives of analysis
2) Identify and describe the alternatives
3) Identify, measure and value costs
4) Identify and measure health consequences and other
impacts of health intervention
5) Discount further costs and effectiveness
6) Account for the uncertainties that may exists in the
analysis
7) Present and interpret results
30.
4.FULL ECONOMIC
EVALUATION
Cost minimization analysis
Cost effectiveness analysis
Cost utility analysis
Cost benefit analysis
2.PARTIAL EVALUATION
Cost outcome description
3 A PARTIAL EVALUATION 3B
Efficacy or
effectiveness
evaluation
Cost analysis
NO
Examines only
consequences
Are both the costs and consequences of the alternatives examined
Examines
only costs
1A PARTIAL EVALUATION 1B
Outcome
description
Cost description
Istherecomparisonoftwoormorealternatives
NO
YES
YES
31. Fissure sealants
Water fluoridation
Tooth brushing(with or without fluoridated toothpaste)
Fluoride mouth rinsing
Fluoride tablets
Oral health education
Dietary counseling
Oral hygiene instructions
Public lectures
Campaigns
32. -Mitchell and Murray; and Houpt and Shey .
the caries prevalence of the community;
the type and costs of the equipment, materials, and
operator
longevity of sealants (most sealant failures occur within
6 months of their placements- Thylstrup and Poulsen )
the selection of patients and teeth to be sealed
and the use of other preventive methods.
33. For cost effectiveness purposes, comparisons
between a preventive and restorative procedure is
not valid.
Comparisons with other preventive measures, which
are less labor intensive, put fissure sealants in a
less favorable site.
The alternative is to view sealant as a treatment for
incipient lesions and a measure aimed at protecting
tooth tissue. Then the comparisons with restorations
become valid.
(Burt 1989;Lewis and Morgan 1994).
34. Half-mouth technique , After 2 years :
3,105 minutes – sealing sound teeth
945 minutes - restoring contra lateral carious teeth
1,017 minutes – sealing molars with early carious
lesions
1,034 minutes - restorations in contra lateral teeth
Sealants are not cost beneficial when placed in initially
sound tooth.
35. If sealants were placed prior to any molar restorations,
the 4-year cost-effectiveness was $10.26 per additional
restoration-free year.
36. 1) Using trained auxiliaries to apply sealants
Trained auxiliaries and Hygienist attain equivalent
retention rates as qualified dentists (Stephen K W et al
1978).
2) Applying most recently developed sealants.
3) Application in areas where proximal caries is low.
37. Seal All strategy
3 strategies Risk Based strategy
Seal None
Outcome measured- Incremental cost per month gained
in a cavity free state over a ten year period.
Risk based strategy improved clinical outcome over seal
none.
Strategy of sealing all further improved outcome but an
additional cost was involved($ 0.08 for each additional
cavity free month gained per tooth).
38. It is the most cost effective public health intervention in
preventing dental caries (US department of Health,
2000; Griffin et al 2001;O’Connell et al,2005).
Center for disease control and prevention (CDC) listed
community water fluoridation as one of the 10 major
public health achievements of the twentieth century
39. The size of the community.
The number of the fluoride injection points required.
The type of equipment to be used.
The amount and type of chemical used.
The number of expertise of water plant personnel.
40. The average cost for a community to fluoridate its water
is estimated to range from approximately $0.50 a year
per person in large communities to approximately $3.00
a year per person in small communities.
For most cities, every $1 invested in water fluoridation
saves $38 in dental treatment costs-ADA
41. Most comprehensive analysis– 44 Florida communities between 1981
and 1989.
Accounted for- Initial one time costs
- Opportunity costs of capital investment
- Annual operational costs of installing a water
fluoridation systems
The initiation and annual operation ranges from $ 0.14
to $5.93 per person with a mean of $ 0.45 per person
serving a total population over 1.6million people.
42. The mean annual per capita cost of fluoridation ranges from
$0.68 for systems serving populations greater than 50,000
(large systems)
and $0.98 for systems serving between 10,000 and 50,000
(medium systems)
to $3.00 for systems serving less than 10,000 (small
systems) (reported in 1999 dollars) (Ringelberg et al. 1992).
43. Compared to the cost of restorative treatment,
water fluoridation actually provides cost savings, a
rare characteristic for community-based disease
prevention strategies (Garcia 1989).
Costs per person for water fluoridation ranges
from $ 0.21 for a population of 4.9 million people to
$ 1.16 for a population of 498 people.
44. O’Connell et al 2005.
Water fluoridation in Colorado resulted in an annual
saving of
$ 148.9 million ($ 60.78 per person).
For smaller communities - $ 2.66/person/year
For larger communities - $0.43/person/year
45. Per capita cost per year, cost-effectiveness analysis
(CEA) and cost-benefit analysis (CBA).
The calculated cost per capita per year was R 0.73
while CEA showed that R 3.95 will be spent to save 1
DMFT.
The cost-benefit ratio of a 2 surface plastic restoration
was R 0.04.
Evaluation of cost for the implementation of water
fluoridation in Gauteng was extremely favorable.
46. In India the approximate per capita cost shall be about
Rs 0.25 per individual per year and the caries reduction
of 50%.
If one assumes a caries increment of one DMFS per
year and the cost of restoring a tooth surface at Rs 40 ,
the cost to benefit ratio is 1:160.
47. It provides the greatest global benefit in reducing caries
among children (Burt, 1998).
It is the most common method of fluoride delivery, with
over 500 million people worldwide benefiting from its
use (WHO,2003).
The WHO is calling for the development of Affordable
Fluoridated Toothpastes (AFT) that are available at price
accessible to populations with low socioeconomic status
(SES) in developing countries.
A WHO study conducted in Indonesia demonstrated that
low cost fluoridated toothpaste can reduce dental caries.
48. The annual cost of saving one DMFS with a supervised
tooth brushing method was US $ 8.80.
The cost of saving one DMFS using community Water
fluoridation in the same area was $ 0.39 (Manau et al
1987)
Community water fluoridation cost effective alternative.
49. Includes gels, varnishes, foams.
Economic studies on PATF must account for
- Opportunity cost of labor
- Materials
- Patient’s time and resources
To reduce costs use dental auxiliaries
50. Canadian study evaluated the cost of fluoride
varnishes and fluoride foams in high risk children
dental hygienist administered the varnish and foams
All costs for hygienists labor, fluoride foam,
Styrofoam trays, fluoride varnishes, brush tips and
cotton rolls were evaluated
Fluoride varnish was more acceptable and less
expensive($3.69 , 5.81 minutes per application)
compared to foam($ 4.11 , 7.86 minutes per
application) .
51. PATF should be targeted to high risk individuals, as low
risk individuals are unlikely to benefit from PATF
treatments (Seppa 2001).
The cost effectiveness of PAFT is arguable because:
1) Costly professional time is required
2) It requires intervention on an individual basis
3) Multiple applications are required each year
(Burt 1998).
52. Public health fluoride mouth rinse programs are
school based and recommended in fluoride deficient
areas.
Labor costs account for approximately 85% of the
total cost of the program(Doherty and Martie, 1987).
Garcia (1989) conducted a study examining the direct
cost of school based mouth rinsing program serving
1.25 million children in 11 states of USA.
Cost of personnel, materials and supplies were
accounted, but it did not account for teachers’ and
volunteers’ time .
53. Annual cost of running a mouth rinse program ranged
from US $ 0.52 to $ 1.78 per child with a mean of $ 1.30
per child.
Doherty et al 1984.
75000 children annual costs ranged from $2.35 to
$8.05 per child
Costs of school based programs fluctuates depending
upon the size of the school population.
54. Fluoride mouth rinsing programs should be implemented
In a population with high risk (Wei and Yiu,1993, Burt,
1998).
Cost effectiveness of this strategy cannot be supported
when other initiatives like water fluoridation or
fluoridated dentifrices are available (Niessen and
Douglass, 1984)
55. The department of dentistry has launched a program in rural area of
Haryana state where the multipurpose workers, health assistants
have been trained to teach the community and fluoride tables are
manufactured by a firm which costs only 5 paisa.
One tablet costing 5 paisa is sufficient for a family of 4 members in
a day.
The monthly expenditure for a family of 4 would be approximately
Rs 1.50.
56. The costs of instituting and operating fluoride
supplement programs are very similar to those of
fluoride mouth rinse programs.
The annual cost of running a dietary fluoride
supplement program was on average US $ 2.53
per child (Garcia 1989).
Yeung CA 2005
Fluoridated milk is a cost effective method of
delivering fluorides.
57. In developed countries, where population has access to
fluoridated water/dentifrice the benefits gained from use
of fluoride supplements is minimal
The costs of a school-based tablet program are low:
Equipment is not necessary
the procedure does not take long
and an entire classroom of children can participate at
once.
58. A 1988 survey of five programs ranging from
7 to 49 schools and 657 to 10,751 children.
found an average direct cost of approximately $2.53 per
child per school year (Garcia 1989).
The costs ranged from $0.81 to $5.40, depending on
whether paid personnel or volunteers supervised the
procedure.
59. The cost and effectiveness of school-based preventive
programs.
Dental health lessons, brushing and flossing, fluoride
tablets and mouth rinsing, and professionally applied
topical fluorides, fissure sealants and water fluoridation.
Communal water fluoridation was reaffirmed as the most
cost-effective means of reducing tooth decay in children.
60. Systematic review of economic evaluation of dental
caries prevention.
1) Performing fissure sealants is a cost demanding means
of caries prevention with questionable cost effectiveness
unless only caries active patients are to be
treated.(evidence inconclusive).
2) Fluoride mouth rinsing – results contradictory (evidence
inconclusive).
62. Fluoride varnishes have not been approved for use in
the United States with an anticaries indication
Varnishes have been used in Europe for 30 years
Many fluoride rinsing programs in Finland have been
replaced with fluoride varnish application programs
(Seppä 1991, Sundberg et al. 1996). Studies conducted
in Canada (Clark et al. 1987)
63. Findings on cost-effectiveness are mixed (Kirkegaard et
al. 1986, Koch et al. 1979, Seppä and Pollanen 1987,
Vehmanen 1993).
64. Smales 1982 –Amalgam more cost effective
Stamm 1983– Favor of sealants
Dennison 1981- Sealants took 29% less time
after four years when compared to amalgam.
Garcia-Godoy1987 – In an office setting, it costs 1.6
times more to treat a tooth than to seal.
65. PRECIPITATION METHOD OF WATER
DEFLUORIDATION
Annual cost (1991) of defluoridation of water at
40 litres / capita / day is Rs.20/- for domestic treatment.
Rs.85/- for community treatment for 5000 population
with F levels of 5 mg/l.
66. The cost of treating
1 litre of fluoride water with 2-5 ppm by IISc method
is 7 paise/litre and
the cost of DDU is ~ Rs.2000/unit.
The IISc method can be scaled up to treat fluoride contaminated
water at community level (500-2000 litres/day).
Field trials of this method at individual house hold –considered
for four villages of Kolar district, Karnataka.
67. The World Development Report states- improved health
contributes to economic growth in 4 ways
(1) It reduces production losses caused by workers’ illness
(2) It permits the use of natural resources that had been
totally or nearly inaccessible due to disease
(3) It increases the enrolment of children in schools and
makes them capable of learning
(4) It makes alternative uses of resources that would
otherwise have to be spent on treatment.
68. If the effectiveness of an intervention has not been
established, an economic evaluation cannot be
considered since there is no basis to estimate health
consequences.
69. Omission of important costs or benefits
Selection of an inappropriate alternative for comparison
Biases in synthesizing clinical data
Inappropriate extrapolation beyond the period observed
in clinical studies?
70. Economic evaluation of health care programs is now
common-place in medicine and is becoming increasingly
important in dentistry.
Increased research in the field of economic evaluation
in conjunction with clinical trials is required in dentistry in
both primary care and hospital settings.
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