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Moore D, Nyakutsikwa B, Allen T, Lam E, Birch S, Tickle M, Pretty IA, Walsh T. How effective and cost-effective is water fluoridation for adults and adolescents? The LOTUS 10-year retrospective cohort study. Community Dent Oral Epidemiol 2024; 52:413-423. [PMID: 38191778 DOI: 10.1111/cdoe.12930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 11/10/2023] [Accepted: 11/19/2023] [Indexed: 01/10/2024]
Abstract
OBJECTIVE To pragmatically assess the clinical and cost-effectiveness of water fluoridation for preventing dental treatment and improving oral health in a contemporary population of adults and adolescents, using a natural experiment design. METHODS A 10-year retrospective cohort study (2010-2020) using routinely collected NHS dental treatment claims data. Participants were patients aged 12 years and over, attending NHS primary dental care services in England (17.8 million patients). Using recorded residential locations, individuals exposed to drinking water with an optimal fluoride concentration (≥0.7 mg F/L) were matched to non-exposed individuals using propensity scores. Number of NHS invasive dental treatments, DMFT and missing teeth were compared between groups using negative binomial regression. Total NHS dental treatment costs and cost per invasive dental treatment avoided were calculated. RESULTS Matching resulted in an analytical sample of 6.4 million patients. Predicted mean number of invasive NHS dental treatments (restorations 'fillings'/extractions) was 3% lower in the optimally fluoridated group (5.4) than the non-optimally fluoridated group (5.6) (IRR 0.969, 95% CI 0.967, 0.971). Predicted mean DMFT was 2% lower in the optimally fluoridated group (IRR 0.984, 95% CI 0.983, 0.985). There was no difference in the predicted mean number of missing teeth per person (IRR 1.001, 95% CI 0.999, 1.003) and no compelling evidence that water fluoridation reduced social inequalities in dental health. Optimal water fluoridation in England 2010-2020 was estimated to cost £10.30 per person (excludes initial set-up costs). NHS dental treatment costs for optimally fluoridated patients 2010-2020 were 5.5% lower, by £22.26 per person (95% CI -£21.43, -£23.09). CONCLUSIONS Receipt of optimal water fluoridation 2010-2020 resulted in very small positive health effects which may not be meaningful for individuals. Existing fluoridation programmes in England produced a positive return on investment between 2010 and 2020 due to slightly lower NHS dental care utilization. This return should be evaluated against the projected costs and lifespan of any proposed capital investment in water fluoridation, including new programmes.
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Affiliation(s)
- Deborah Moore
- Faculty of Biology, Medicine and Health, Division of Dentistry, The University of Manchester, Manchester, UK
| | - Blessing Nyakutsikwa
- Faculty of Biology, Medicine and Health, Division of Dentistry, The University of Manchester, Manchester, UK
| | - Thomas Allen
- Manchester Centre for Health Economics, The University of Manchester, Manchester, UK
| | | | - Stephen Birch
- Manchester Centre for Health Economics, The University of Manchester, Manchester, UK
| | - Martin Tickle
- Faculty of Biology, Medicine and Health, Division of Dentistry, The University of Manchester, Manchester, UK
| | - Iain A Pretty
- Faculty of Biology, Medicine and Health, Division of Dentistry, The University of Manchester, Manchester, UK
| | - Tanya Walsh
- Faculty of Biology, Medicine and Health, Division of Dentistry, The University of Manchester, Manchester, UK
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Holloway JA, Chestnutt IG. It's not just about the money: recruitment and retention of clinical staff in general dental practice - part 1: dentists. Prim Dent J 2024; 13:38-54. [PMID: 38520198 DOI: 10.1177/20501684241232212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/25/2024]
Abstract
Increasing difficulties in recruitment and retention of dentists and dental care professionals in general dental practice in the UK is affecting delivery of NHS dental services. Reports of dissatisfaction among the general dental practice workforce indicate there is a significant risk to the future dental workforce supply which will affect access to dental care and worsen oral health inequalities. Understanding the factors related to job satisfaction and dissatisfaction of dental professionals would be useful in managing recruitment and retention issues and ensure a dental workforce exists which is able to meet the needs of the population. The aim of this literature review was to identify factors which contribute to job satisfaction and dissatisfaction of clinical staff in general dental practice. Database searching was conducted systematically through PubMed/Medline, Scopus, Ovid, and the National Grey Literature Collection. Part 1 of this two-part series discusses the factors relating to dentists. Twenty-two relevant articles were identified, which were qualitatively analysed using Herzberg's motivation-hygiene theory as an analysis tool. Target-driven and restrictive contractual arrangements are a major factor contributing to dissatisfaction of dentists, as well as time pressures, poor quality equipment, and unfair remuneration. Dental contract reform should aim to minimise factors contributing to dissatisfaction and increase factors which increase satisfaction, if sufficient numbers of dentists are to be persuaded to continue to provide state-funded dentistry.
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Affiliation(s)
- Jessica A Holloway
- Jessica A. Holloway MChD/BChD, MPH, PhD, FHEA Specialty Registrar in Dental Public Health, Public Health Wales, Cardiff, UK
- Ivor G. Chestnutt BDS, MPH, PhD, FDS(DPH)RCSEd, FDS RCSEng, FDS RCPSGlas, FFPH, DDPH RCS ENG, FHEA Professor and Honorary Consultant in Dental Public Health, Cardiff University, Cardiff, UK
| | - Ivor G Chestnutt
- Jessica A. Holloway MChD/BChD, MPH, PhD, FHEA Specialty Registrar in Dental Public Health, Public Health Wales, Cardiff, UK
- Ivor G. Chestnutt BDS, MPH, PhD, FDS(DPH)RCSEd, FDS RCSEng, FDS RCPSGlas, FFPH, DDPH RCS ENG, FHEA Professor and Honorary Consultant in Dental Public Health, Cardiff University, Cardiff, UK
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3
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Sandom F, Hearnshaw S, Grant S, Williams L, Brocklehurst P. The in-practice prevention programme: an example of flexible commissioning from Yorkshire and the Humber. Br Dent J 2022:10.1038/s41415-022-4140-y. [PMID: 35383286 PMCID: PMC8982659 DOI: 10.1038/s41415-022-4140-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 08/10/2021] [Indexed: 11/29/2022]
Abstract
Introduction An In-Practice Prevention (IPP) programme was developed by the Local Dental Network in the North Yorkshire and the Humber area in England in response to an oral health needs assessment. The underpinning logic model drew on a flexible commissioning approach and aimed to incentivise dental teams with NHS contracts to promote the delivery of prevention. This used care pathways that involved the whole dental team and was cost-neutral.Aim The programme was evaluated using realist methodology to identify 'what works, in which circumstances, how and for who?'.Design Realist evaluations are explanatory in nature and attempt to understand the factors that appear to influence the success (or not) of an intervention, rather than demonstrating causality.Methods and results Following a review of the pertinent literature, semi-structured interviews and focus groups, five theory areas were considered to be critical to the delivery of IPP. In order of stated priority, these were: 1) clinical leadership; 2) 'skill mix'; 3) financial incentives; 4) institutional logic/practice culture; and 5) behaviour change.Conclusion The results appear to show that clinically-led programmes could offer value to dental commissioners within a flexible commissioning model, although this would need to be further tested using an experiment design.
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Affiliation(s)
- Fiona Sandom
- School of Health Sciences, Bangor University, UK
| | | | - Siobhan Grant
- Public Health England, North Yorkshire and the Humber Area, UK
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Kalmus O, Chalkley M, Listl S. Effects of provider incentives on dental X-raying in NHS Scotland: what happens if patients switch providers? THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2022; 23:59-65. [PMID: 34255240 PMCID: PMC8882106 DOI: 10.1007/s10198-021-01348-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 07/01/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND In many market settings individuals are encouraged to switch health care providers as a means of ensuring more competition. Switching may have a potentially undesirable side effect of increasing unnecessary treatment. Focusing on the most common source of medical radiation (dental X-rays), the purpose of this study was to assess whether, upon switching dentist, X-ray exposure increases depending on the type of provider payment. METHODS The analysis used longitudinal data from 2005 to 2016 covering a 5% random sample of the Scottish adult population covered by the National Health Service (NHS). Multiple fixed-effects panel regression analyses were employed to determine the correlation of provider remuneration with patients' likelihood of receiving an X-ray upon switching to a new dentist other things equal. A broad set of covariates including a patient's copayment status was controlled for. RESULTS Upon switching to a dentist who was paid fee-for-service, patients had a by 9.6%-points (95% CI 7.4-11.8%) higher probability of receiving an X-ray, compared to switching to a salaried dentist. Results were robust when accounting for patient exemption status, as well as unobserved patient and dentist characteristics. CONCLUSIONS In comparison to staying with the same dentist, patients may be exposed to substantially more X-rays upon switching to a dentist who is paid fee-for-service. There may need to be better guidance and regulation to protect the health of those who have to switch provider due to moving and greater caution in advocating voluntary switching.
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Affiliation(s)
- Olivier Kalmus
- Section for Translational Health Economics, Department of Conservative Dentistry, University Hospital Heidelberg, Heidelberg, Germany
| | | | - Stefan Listl
- Section for Translational Health Economics, Department of Conservative Dentistry, University Hospital Heidelberg, Heidelberg, Germany.
- Department of Dentistry - Quality and Safety of Oral Health Care, Radboudumc - Radboud Institute of Health Sciences, Nijmegen, Netherlands.
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Brocklehurst P, Hoare Z, Woods C, Williams L, Brand A, Shen J, Breckons M, Ashley J, Jenkins A, Gough L, Preshaw P, Burton C, Shepherd K, Bhattarai N. Dental therapists compared with general dental practitioners for undertaking check-ups in low-risk patients: pilot RCT with realist evaluation. HEALTH SERVICES AND DELIVERY RESEARCH 2021. [DOI: 10.3310/hsdr09030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Background
Many dental ‘check-ups’ in the NHS result in no further treatment. The patient is examined by a dentist and returned to the recall list for a further check-up, commonly in 6 or 12 months’ time. As the oral health of regular dental attenders continues to improve, it is likely that an increasing number of these patients will be low risk and will require only a simple check-up in the future, with no further treatment. This care could be delivered by dental therapists. In 2013, the body responsible for regulating the dental profession, the General Dental Council, ruled that dental therapists could see patients directly and undertake check-ups and routine dental treatments (e.g. fillings). Using dental therapists to undertake check-ups on low-risk patients could help free resources to meet the future challenges for NHS dentistry.
Objectives
The objectives were to determine the most appropriate design for a definitive study, the most appropriate primary outcome measure and recruitment and retention rates, and the non-inferiority margin. We also undertook a realist-informed process evaluation and rehearsed the health economic data collection tool and analysis.
Design
A pilot randomised controlled trial over a 15-month period, with a realist-informed process evaluation. In parallel, we rehearsed the health economic evaluation and explored patients’ preferences to inform a preference elicitation exercise for a definitive study.
Setting
The setting was NHS dental practices in North West England.
Participants
A total of 217 low-risk patients in eight high-street dental practices participated.
Interventions
The current practice of using dentists to provide NHS dental check-ups (treatment as usual; the control arm) was compared with using dental therapists to provide NHS dental check-ups (the intervention arm).
Main outcome measure
The main outcome measure was difference in the proportion of sites with bleeding on probing among low-risk patients. We also recorded the number of ‘cross-over’ referrals between dentists and dental therapists.
Results
No differences were found in the health status of patients over the 15 months of the pilot trial, suggesting that non-inferiority is the most appropriate design. However, bleeding on probing suffered from ‘floor effects’ among low-risk patients, and recruitment rates were moderately low (39.7%), which suggests that an experimental design might not be the most appropriate. The theory areas that emerged from the realist-informed process evaluation were contractual, regulatory, institutional logistics, patients’ experience and logistics. The economic evaluation was rehearsed and estimates of cost-effectiveness made; potential attributes and levels that can form the basis of preference elicitation work in a definitive study were determined.
Limitations
The pilot was conducted over a 15-month period only, and bleeding on probing appeared to have floor effects. The number of participating dental practices was a limitation and the recruitment rate was moderate.
Conclusions
Non-inferiority, floor effects and moderate recruitment rates suggest that a randomised controlled trial might not be the best evaluative design for a definitive study in this population. The process evaluation identified multiple barriers to the use of dental therapists in ‘high-street’ practices and added real value.
Future work
Quasi-experimental designs may offer more promise for a definitive study alongside further realist evaluation.
Trial registration
Current Controlled Trials ISRCTN70032696.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 3. See the NIHR Journals Library website for further project information.
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Affiliation(s)
| | - Zoe Hoare
- School of Health Sciences, Bangor University, Bangor, UK
| | - Chris Woods
- School of Health Sciences, Bangor University, Bangor, UK
| | - Lynne Williams
- School of Health Sciences, Bangor University, Bangor, UK
| | - Andrew Brand
- School of Health Sciences, Bangor University, Bangor, UK
| | - Jing Shen
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Matthew Breckons
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | | | - Alison Jenkins
- School of Health Sciences, Bangor University, Bangor, UK
| | | | - Philip Preshaw
- Faculty of Dentistry, National University of Singapore, Singapore
- Faculty of Dentistry, Newcastle University, Newcastle upon Tyne, UK
| | - Christopher Burton
- School of Allied and Public Health Professions, Canterbury Christ Church University, Canterbury, UK
| | - Karen Shepherd
- Patient and public involvement representative, Bangor, UK
| | - Nawaraj Bhattarai
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
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Niesten D, Gerritsen AE, Leve V. Barriers and facilitators to integrate oral health care for older adults in general (basic) care in East Netherlands. Part 1: Normative integration. Gerodontology 2020; 38:154-165. [PMID: 33274776 DOI: 10.1111/ger.12507] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 10/05/2020] [Accepted: 10/17/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVE to synthesise a framework of barriers and facilitators in the normative integration of oral health care (OHC) into general health care for frail older adults at macro (system), meso (organisation and interprofessional integration) and micro (clinical practice) levels. BACKGROUND Identification of these barriers and facilitators is expected to promote better and more appropriate care. METHODS For this qualitative study, comprising 41 participants, representatives of 10 different groups of (professional) care providers, and OHC receivers (home-dwelling, and nursing home patients) in East Netherlands were interviewed. Transcripts of the in-depth, topic-guided interviews were thematically analysed. In a subsequent workshop with 52 stakeholders, results and interpretations were discussed and refined. RESULTS Two main themes were identified: (1) a compartmentalised care culture in which OHC and general health care are seen as two separate realms, and (2) prioritisation, awareness and attitude regarding OHC integration. Subthemes such as low political attention (macro level); unclear responsibilities, hierarchical relations and the lack of vision of organisations (meso level); and poor awareness and low prioritisation by care providers and patients (micro level) were identified as potential barriers. Subthemes such as leadership (meso level), and the supportive personality of individual caregivers and ownership of patients (micro level) were identified as facilitators. CONCLUSION Barriers and facilitators in normative OHC integration in The Netherlands are interrelated and apparent at macro-, meso- and micro levels. They are mainly related to (a) a compartmentalised care culture, and (b) related low prioritisation, and poor awareness of and attitude towards (integration of) oral health (care).
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Affiliation(s)
- Dominique Niesten
- College of Dental Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Anneloes E Gerritsen
- College of Dental Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Verena Leve
- Institut für Allgemeinmedizin, Heinrich-Heine-Universität, Düsseldorf, Germany
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7
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Virdee SS, Ravaghi V, Camilleri J, Cooper P, Tomson P. Current trends in endodontic irrigation amongst general dental practitioners and dental schools within the United Kingdom and Ireland: a cross-sectional survey. Br Dent J 2020:10.1038/s41415-020-1984-x. [PMID: 32855518 DOI: 10.1038/s41415-020-1984-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Aims To investigate current trends in endodontic irrigation amongst general dental practitioners (GDPs) and dental schools within UK and Ireland. Secondly, to evaluate if significant differences exist between the irrigant practices of National Health Service (NHS) and private GDPs.Methodology In 2019, an online questionnaire was distributed to the 18 dental schools within the UK and Ireland and 8,568 GDPs. These surveys explored current trends in teaching and usage of endodontic irrigants. Chi-squared tests were performed to make comparisons between NHS and private GDPs (α <0.01).Results All 18 dental schools (100%) and 495 GDPs (6%) returned valid questionnaires. Three hundred and thirty (66.7%) practitioners were NHS and 165 (33.3%) were private. There was strong consensus on irrigation teaching amongst dental schools. These results aligned with GDP responses in terms of irrigant selection (sodium hypochlorite [NaOCl]); NaOCl concentration (≤3%); ethylenediaminetetraacetic acid (EDTA) contact time (>0-5 minutes); final rinse protocols (penultimate EDTA rinse); irrigant temperature (room); and agitation techniques (manual dynamic activation; >0-60 seconds). There was, however, considerable variation in NaOCl contact time and GDPs infrequently used chelating agents or agitation techniques. Compared with private practitioners, NHS GDPs used significantly lower NaOCl contact times and concentrations, less EDTA and activation techniques, and more chlorhexidine (P <0.01).Conclusions Overall, irrigation teaching within the UK and Ireland is consistent and evidence-based. Furthermore, trends in irrigant usage amongst UK GDPs are now more aligned with these teaching practices. Significant differences were, however, observed between NHS and private practitioners.
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Affiliation(s)
- Satnam Singh Virdee
- Clinical Lecturer & Speciality Registrar in Restorative Dentistry, PhD Student, University of Birmingham School of Dentistry, Mill Pool Way, Birmingham, UK; Part-Time General Dental Practitioner, Abbey House Dental Practice, 9 Abbey Street, Stone, ST15 8PA, UK.
| | - Vahid Ravaghi
- Lecturer in Dental Public Health, University of Birmingham School of Dentistry, Mill Pool Way, Birmingham, UK
| | - Josette Camilleri
- Reader in Restorative Dentistry, University of Birmingham School of Dentistry, Mill Pool Way, Birmingham, UK
| | - Paul Cooper
- Professor of Oral Biology, Department of Oral Sciences, Sir John Walsh Research Institute, Faculty of Dentistry, University of Otago, Dunedin, New Zealand
| | - Phillip Tomson
- Senior Clinical Lecturer & Consultant in Restorative Dentistry, University of Birmingham, Mill Pool Way, Birmingham, B5 7EG, UK
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8
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Hill H, Howarth E, Walsh T, Tickle M, Birch S, Brocklehurst P. The impact of changing provider remuneration on clinical activity and quality of care: Evaluation of a pilot NHS contract in Northern Ireland. Community Dent Oral Epidemiol 2020; 48:395-401. [DOI: 10.1111/cdoe.12544] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 05/02/2020] [Accepted: 05/03/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Harry Hill
- School of Health and Related Research University of Sheffield Sheffield UK
| | | | - Tanya Walsh
- School of Dentistry University of Manchester Manchester UK
| | - Martin Tickle
- School of Dentistry University of Manchester Manchester UK
| | - Stephen Birch
- Health Services Research & Primary Care University of Manchester Manchester UK
- Centre for Business and Economics of Health University of Queensland Australia
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9
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The relationship between professional and commercial obligations in dentistry: a scoping review. Br Dent J 2020; 228:117-122. [DOI: 10.1038/s41415-020-1195-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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10
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Brocklehurst P, Tickle M, Birch S, McDonald R, Walsh T, Goodwin TL, Hill H, Howarth E, Donaldson M, O’Carolan D, Fitzpatrick S, McCrory G, Slee C. Impact of changing provider remuneration on NHS general dental practitioner services in Northern Ireland: a mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2020. [DOI: 10.3310/hsdr08060] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background
Policy-makers wanted to reform the NHS dental contract in Northern Ireland to contain costs, secure access and incentivise prevention and quality. A pilot project was undertaken to remunerate general dental practitioners using a capitation-based payment system rather than the existing fee-for-service system.
Objective
To investigate the impact of this change in remuneration.
Design
Mixed-methods design using a difference-in-difference evaluation of clinical activity levels, a questionnaire of patient-rated outcomes and qualitative assessment of general dental practitioners’ and patients’ views.
Setting
NHS dental practices in Northern Ireland.
Participants
General dental practitioners and patients in 11 intervention practices and 18 control practices.
Interventions
Change from fee for service to a capitation-based system for 1 year and then reversion back to fee for service.
Main outcome measures
Access to care, activity levels, service mix and financial impact, and patient-rated outcomes of care.
Results
The difference-in-difference analyses showed significant and rapid changes in the patterns of care provided by general dental practitioners to patients (compared with the control practices) when they moved from a fee-for-service system to a capitation-based remuneration system. The number of registered patients in the intervention practices compared with the control practices showed a small but statistically significant increase during the capitation period (p < 0.01), but this difference was small. There were statistically significant reductions in the volume of activity across all treatments in the intervention practices during the capitation period, compared with the control practices. This produced a concomitant reduction in patient charge revenue of £2403 per practice per month (p < 0.05). All outcome measures rapidly returned to baseline levels following reversion from the capitation-based system back to a fee-for-service system. The analysis of the questionnaires suggests that patients did not appear to notice very much change. Qualitative interviews showed variation in general dental practitioners’ behaviour in response to the intervention and how they managed the tension between professional ethics and maximising the profits of their business. Behaviours were also heavily influenced by local context. Practice principals preferred the capitation model as it freed up time and provided opportunities for private work, whereas capitation payments were seen by some principals as a ‘retainer fee’ for continuing to provide NHS care. Non-equity-owning associates perceived the capitation model as a financial risk.
Limitations
The active NHS pilot period was only 1 year, which may have limited the scope for meaningful change. The number of sites was restricted by the financial budget for the NHS pilot.
Conclusions
General dental practitioners respond rapidly and consistently to changes in remuneration, but differences were found in the extent of this change by practice and provider type. A move from a fee-for-service system to a capitation-based system had little impact on access but produced large reductions in clinical activity and patient charge income. Patients noticed little difference in the service that they received.
Future work
With changing population need and increasing financial pressure on the NHS, research is required on how to most efficiently meet the expectations of patients within an affordable cost envelope. Work is also needed to identify and evaluate interventions that can complement changes in remuneration to meet policy goals.
Trial registration
Current Controlled Trials ISRCTN29840057.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 6. See the NIHR Journals Library website for further project information.
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Affiliation(s)
| | - Martin Tickle
- School of Dentistry, University of Manchester, Manchester, UK
| | - Stephen Birch
- Health Services Research & Primary Care, University of Manchester, Manchester, UK
| | - Ruth McDonald
- Manchester Business School, University of Manchester, Manchester, UK
| | - Tanya Walsh
- School of Dentistry, University of Manchester, Manchester, UK
| | | | - Harry Hill
- School of Health and Related Research, University of Sheffield, Sheffield, UK
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11
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Colgan SM, Randall PG, Porter JDH. 'Bridging the gap' - A survey of medical GPs' awareness of child dental neglect as a marker of potential systemic child neglect. Br Dent J 2018; 224:717-725. [PMID: 29747168 DOI: 10.1038/sj.bdj.2018.349] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/13/2017] [Indexed: 11/09/2022]
Affiliation(s)
- S M Colgan
- Consultant GP and Visiting Academic, Medical Education Academic Unit, Faculty of Medicine, University of Southampton, B85, Highfield Campus, University Road, Southampton, SO17 1BJ, UK
| | - P G Randall
- Orthopaedic physician GPSI. St. Mary's Hospital, Newport, Isle of Wight, UK
| | - J D H Porter
- Professor of International Health, London School of Hygiene and Tropical Medicine, London, UK
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12
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Chalkley M, Listl S. First do no harm - The impact of financial incentives on dental X-rays. JOURNAL OF HEALTH ECONOMICS 2018; 58:1-9. [PMID: 29408150 DOI: 10.1016/j.jhealeco.2017.12.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 09/01/2017] [Accepted: 12/23/2017] [Indexed: 06/07/2023]
Abstract
This article assesses the impact of dentist remuneration on the incidence of potentially harmful dental X-rays. We use unique panel data which provide details of 1.3 million treatment claims by Scottish NHS dentists made between 1998 and 2007. Controlling for unobserved heterogeneity of both patients and dentists we estimate a series of fixed-effects models that are informed by a theoretical model of X-ray delivery and identify the effects on dental X-raying of dentists moving from a fixed salary to fee-for-service and patients moving from co-payment to exemption. We establish that there are significant increases in X-rays when dentists receive fee-for-service rather than salary payments and when patients are made exempt from payment.
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Affiliation(s)
| | - Stefan Listl
- Section for Translational Health Economics, Medical Faculty Heidelberg - Department of Conservative Dentistry, Heidelberg University, Germany and Department of Dentistry - Quality and Safety of Oral Health Care, Radboud University, Nijmegen, Netherlands.
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13
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Chenot R. [Pay for performance in dental care: A systematic narrative review of quality P4P models in dental care]. ZEITSCHRIFT FUR EVIDENZ, FORTBILDUNG UND QUALITAT IM GESUNDHEITSWESEN 2017; 127-128:42-55. [PMID: 28838794 DOI: 10.1016/j.zefq.2017.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 06/02/2017] [Accepted: 06/05/2017] [Indexed: 06/07/2023]
Abstract
BACKGROUND Pay for performance (P4P) links reimbursement to the achievement of quality objectives. Experiences with P4P instruments and studies on their effects are available for the inpatient sector. A systematic narrative review brings together findings concerning the use and the effects of P4P, especially in dental care. METHODS A systematic literature search in PubMed and the Cochrane Library for reimbursement models using quality indicators provided 77 publications. Inclusion criteria were: year of publication not older than 2007, dental sector, models of quality-oriented remuneration, quality of care, quality indicators. 27 publications met the inclusion criteria and were evaluated with regard to the instruments and effects of P4P. The database search was supplemented by a free search on the Internet as well as a search in indicator databases and portals. The results of the included studies were extracted and summarized narratively. RESULTS 27 studies were included in the review. Performance-oriented remuneration is an instrument of quality competition. In principle, P4P is embedded in an existing remuneration system, i.e., it does not occur in isolation. In the United States, England and Scandinavia, models are currently being tested for quality-oriented remuneration in dental care, based on quality indicators. The studies identified by the literature search are very heterogeneous and do not yield comparable endpoints. Difficulties are seen in the reproducibility of the quality of dental care with regard to certain characteristics which still have to be defined as quality-promoting properties. Risk selection cannot be ruled out, which may have an impact on structural quality (access to care, coordination). CONCLUSION There were no long-term effects of P4P on the quality of care. In the short and medium term, adverse effects on the participants' motivation as well as shifting effects towards the private sector are described. A prerequisite for the functioning of P4P is the definition of clear targets and measuring parameters. Furthermore, evidence-based quality indicators have to be developed that validly depict quality differences. It is yet unknown whether P4P will have long-term effects or whether the quality of dental care will increase.
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Affiliation(s)
- Regine Chenot
- Zentrum Zahnärztliche Qualität (ZZQ), Berlin, Deutschland.
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Hill H, Birch S, Tickle M, McDonald R, Donaldson M, O'Carolan D, Brocklehurst P. Does capitation affect the delivery of oral healthcare and access to services? Evidence from a pilot contact in Northern Ireland. BMC Health Serv Res 2017; 17:175. [PMID: 28264677 PMCID: PMC5339966 DOI: 10.1186/s12913-017-2117-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2016] [Accepted: 02/24/2017] [Indexed: 11/22/2022] Open
Abstract
Background In May 2009, the Northern Ireland government introduced General Dental Services (GDS) contracts based on capitation in dental practices newly set up by a corporate dental provider to promote access to dental care in populations that had previously struggled to secure service provision. Dental service provision forms an important component of general health services for the population, but the implications of health system financing on care delivered and the financial cost of services has received relatively little attention in the research literature. The aim of this study is to evaluate the policy effect capitation payment in recently started corporate practices had on the delivery of primary oral healthcare in Northern Ireland and access to services. Methods We analysed the policy initiative in Northern Ireland as a natural experiment to find the impact on healthcare delivery of the newly set up corporate practices that use a prospective capitation system to remunerate primary care dentists. Data was collected from GDS claim forms submitted to the Business Services Organisation (BSO) between April 2011 and October 2014. Health and Social Care Board (HSCB) practices operating within a capitation system were matched to a control group, who were remunerated using a retrospective fee-for-service system. Results No evidence of patient selection was found in the HSCB practices set up by a corporate provider and operated under capitation. However, patients were less likely to visit the dentist and received less treatment when they did attend, compared to those belonging to the control group (P < 0.05). The extent of preventive activity offered and the patient payment charge revenue did not differ between the two practice groups. Conclusion Although remunerating NHS primary care dentists in newly set up corporate practices using a prospective capitation system managed costs within healthcare, there is evidence that this policy may have reduced access to care of registered patients. Electronic supplementary material The online version of this article (doi:10.1186/s12913-017-2117-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Harry Hill
- School of Dentistry, University of Manchester, Manchester, M13 9PL, UK. .,Manchester Centre for Health Economics, University of Manchester, Manchester, M13 9PL, UK. .,Centre for Health Economics, Institute of Population Health Faculty of Medical and Human Sciences, University of Manchester, Room 4.311, Jean McFarlane Building, Oxford Road, Manchester, M13 9PL, UK.
| | - Stephen Birch
- Manchester Centre for Health Economics, University of Manchester, Manchester, M13 9PL, UK.,Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, L8S 4K1, Canada
| | - Martin Tickle
- School of Dentistry, University of Manchester, Manchester, M13 9PL, UK
| | - Ruth McDonald
- Manchester Business School, University of Manchester, Manchester, M13 9PL, UK
| | | | | | - Paul Brocklehurst
- NWORTH Clinical Trials Unit, Bangor University, Bangor, Gwynedd, LL57 2PZ, UK
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Brocklehurst P, Birch S, McDonald R, Hill H, O’Malley L, Macey R, Tickle M. Determining the optimal model for role substitution in NHS dental services in the UK: a mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2016. [DOI: 10.3310/hsdr04220] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundMaximising health gain for a given level and mix of resources is an ethical imperative for health-service planners. Approximately half of all patients who attend a regular NHS dental check-up do not require any further treatment, whereas many in the population do not regularly attend. Thus, the most expensive resource (the dentist) is seeing healthy patients at a time when many of those with disease do not access care. Role substitution in NHS dentistry, where other members of the dental team undertake the clinical tasks previously provided by dentists, has the potential to increase efficiency and the capacity to care and lower costs. However, no studies have empirically investigated the efficiency of NHS dental provision that makes use of role substitution.Research questionsThis programme of research sought to address three research questions: (1) what is the efficiency of NHS dental teams that make use of role substitution?; (2) what are the barriers to, and facilitators of, role substitution in NHS dental practices?; and (3) how do incentives in the remuneration systems influence the organisation of these inputs and production of outputs in the NHS?DesignData envelopment analysis was used to develop a productive efficiency frontier for participating NHS practices, which were then compared on a relative basis, after controlling for patient and practice characteristics. External validity was tested using stochastic frontier modelling, while semistructured interviews explored the views of participating dental teams and their patients to role substitution.SettingNHS ‘high-street’ general dental practices.Participants121 practices across the north of England.InterventionsNo active interventions were undertaken.Main outcome measuresRelative efficiency of participating NHS practices, alongside a detailed narrative of their views about role substitution dentistry. Social acceptability for patients.ResultsThe utilisation of non-dentist roles in NHS practices was relatively low, the most common role type being the dental hygienist. Increasing the number of non-dentist team members reduced efficiency. However, it was not possible to determine the relative efficiency of individual team members, as the NHS contracts only with dentists. Financial incentives in the NHS dental contract and the views of practice principals (i.e. senior staff members) were equally important. Bespoke payment and referral systems were required to make role substitution economically viable. Many non-dentist team members were not being used to their full scope of practice and constraints on their ability to prescribe reduced efficiency further. Many non-dentist team members experienced a precarious existence, commonly being employed at multiple practices. Patients had a low level of awareness of the different non-dentist roles in a dental team. Many exhibited an inherent trust in the professional ‘system’, but prior experience of role substitution was important for social acceptability.ConclusionsBetter alignment between the financial incentives within the NHS dental contract and the use of role substitution is required, although professional acceptability remains critical.Study limitationsOutput data collected did not reflect the quality of care provided by the dental team and the input data were self-reported.Future workFurther work is required to improve the evidence base for the use of role substitution in NHS dentistry, exploring the effects and costs of provision.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
| | - Stephen Birch
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Ruth McDonald
- Manchester Business School, University of Manchester, Manchester, UK
| | - Harry Hill
- School of Dentistry, University of Manchester, Manchester, UK
| | - Lucy O’Malley
- School of Dentistry, University of Manchester, Manchester, UK
| | - Richard Macey
- School of Dentistry, University of Manchester, Manchester, UK
| | - Martin Tickle
- School of Dentistry, University of Manchester, Manchester, UK
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Holmes RD, Steele JG, Donaldson C, Exley C. Learning from contract change in primary care dentistry: A qualitative study of stakeholders in the north of England. Health Policy 2015; 119:1218-25. [PMID: 25765782 PMCID: PMC4561527 DOI: 10.1016/j.healthpol.2015.02.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Revised: 02/16/2015] [Accepted: 02/17/2015] [Indexed: 12/01/2022]
Abstract
Commissioners’ ability to reallocate resources between contracts is constrained. Patients are unclear about the costs of dental treatment and the NHS charge bands. Dentists dislike the target-based approach involving units of dental activity. Disease prevention is not adequately rewarded under the current dental contract. The quality of dental care provided by dentists should be measured and rewarded.
The aim of this research was to explore and synthesise learning from stakeholders (NHS dentists, commissioners and patients) approximately five years on from the introduction of a new NHS dental contract in England. The case study involved a purposive sample of stakeholders associated with a former NHS Primary Care Trust (PCT) in the north of England. Semi-structured interviews were conducted with 8 commissioners of NHS dental services and 5 NHS general dental practitioners. Three focus group meetings were held with 14 NHS dental patients. All focus groups and interviews were audio recorded and transcribed verbatim. The data were analysed using a framework approach. Four themes were identified: ‘commissioners’ views of managing local NHS dental services’; ‘the risks of commissioning for patient access’; ‘costs, contract currency and commissioning constraints’; and ‘local decision-making and future priorities’. Commissioners reported that much of their time was spent managing existing contracts rather than commissioning services. Patients were unclear about the NHS dental charge bands and dentists strongly criticised the contract's target-driven approach which was centred upon them generating ‘units of dental activity’. NHS commissioners remained relatively constrained in their abilities to reallocate dental resources amongst contracts. The national focus upon practitioners achieving their units of dental activity appeared to outweigh interest in the quality of dental care provided.
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Affiliation(s)
- Richard D Holmes
- Centre for Oral Health Research, School of Dental Sciences, Newcastle University, Framlington Place, Newcastle upon Tyne NE2 4BW, UK.
| | - Jimmy G Steele
- Centre for Oral Health Research, School of Dental Sciences, Newcastle University, Framlington Place, Newcastle upon Tyne NE2 4BW, UK.
| | - Cam Donaldson
- Yunus Centre for Social Business and Health, Glasgow Caledonian University, Level 3-Buchanan House, 58 Port Dundas Road, Glasgow G4 0BA, UK.
| | - Catherine Exley
- Institute of Health & Society, Newcastle University, The Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne NE2 4AX, UK.
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Raittio E, Kiiskinen U, Helminen S, Aromaa A, Suominen AL. Dental attendance among adult Finns after a major oral health care reform. Community Dent Oral Epidemiol 2014; 42:591-602. [DOI: 10.1111/cdoe.12117] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Accepted: 05/26/2014] [Indexed: 11/28/2022]
Affiliation(s)
| | | | | | - Arpo Aromaa
- Institute for Health and Welfare (THL); Helsinki Finland
| | - Anna Liisa Suominen
- University of Eastern Finland; Kuopio Finland
- Institute for Health and Welfare (THL); Helsinki Finland
- Department of Oral and Maxillofacial Surgery; Kuopio University Hospital; Kuopio Finland
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Listl S, Chalkley M. Provider payment bares teeth: Dentist reimbursement and the use of check-up examinations. Soc Sci Med 2014; 111:110-6. [DOI: 10.1016/j.socscimed.2014.04.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2013] [Revised: 04/09/2014] [Accepted: 04/15/2014] [Indexed: 10/25/2022]
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Brocklehurst P, Price J, Glenny A, Tickle M, Birch S, Mertz E, Grytten J. The effect of different methods of remuneration on the behaviour of primary care dentists. Cochrane Database Syst Rev 2013; 2013:CD009853. [PMID: 24194456 PMCID: PMC6544809 DOI: 10.1002/14651858.cd009853.pub2] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Methods of remuneration have been linked with the professional behaviour of primary care physicians. In dentistry, this can be exacerbated as clinicians operate their practices as businesses and take the full financial risk of the provision of services. The main methods for remunerating primary care dentists include fee-for-service, fixed salary and capitation payments. The aim of this review was to determine the impact that these remuneration mechanisms have upon primary care dentists' behaviour. OBJECTIVES To evaluate the effects of different methods of remuneration on the level and mix of activities provided by primary care dentists and the impact this has on patient outcomes. SEARCH METHODS We searched the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 7, 2013); MEDLINE (Ovid) (1947 to 11 June 2013); EMBASE (Ovid) (1947 to 11 June 2013); EconLit (1969 to 11 June 2013); the NHS Economic Evaluation Database (EED) (11 June 2013); and the Health Economic Evaluations Database (HEED) (11 June 2013). We conducted cited reference searches for the included studies in ISI Web of Knowledge; searched grey literature sources; handsearched selected journals; and contacted authors of relevant studies. SELECTION CRITERIA Primary care dentists were defined as clinicians that deliver routine or mainstream dental care in a primary care environment. We included randomised controlled trials (RCTs), non-randomised controlled clinical trials (NRCTs), controlled before-after (CBA) studies and interrupted time series (ITS) studies. The methods of remuneration that we considered were: fee-for-service, fixed salary and capitation payments. Primary outcome measures were: measures of clinical activity; volume of clinical activity undertaken; time taken and clinical session length, or both; clinician type utilised; measures of health service utilisation; access and attendance as a proportion of the population; re-attendance rates; recall frequency; levels of oral health inequalities; non-attendance rates; healthcare costs; measures of patient outcomes; disease reduction; health maintenance; and patient satisfaction. We also considered measures of practice profitability/income and any reported unintended effects of the included methods of remuneration. DATA COLLECTION AND ANALYSIS Three of the review authors (PRB, JP, AMG) independently reviewed titles and abstracts and resolved disagreements by discussion. The same three review authors undertook data extraction and assessed the quality of the evidence from all the studies that met the selection criteria, according to Cochrane Collaboration procedures. MAIN RESULTS Two cluster-RCTs, with data from 503 dental practices, representing 821 dentists and 4771 patients, met the selection criteria. We judged the risk of bias to be high for both studies and the overall quality of the evidence was low/very low for all outcomes, as assessed using the GRADE approach.One study used a factorial design to investigate the impact of fee-for-service and an educational intervention on the placement of fissure sealants in permanent molar teeth. The authors reported a statistically significant increase in clinical activity in the arm that was incentivised with a fee-for-service payment. However, the study was conducted in the four most deprived areas of Scotland, so the applicability of the findings to other settings may be limited. The study did not report data on measures of health service utilisation or measures of patient outcomes.The second study used a parallel group design undertaken over a three-year period to compare the impact of capitation payments with fee-for-service payments on primary care dentists' clinical activity. The study reported on measures of clinical activity (mean percentage of children receiving active preventive advice, health service utilisation (mean number of visits), patient outcomes (mean number of filled teeth, mean percentage of children having one or more teeth extracted and the mean number of decayed teeth) and healthcare costs (mean expenditure). Teeth were restored at a later stage in the disease process in the capitation system and the clinicians tended to see their patients less frequently and tended to carry out fewer fillings and extractions, but also tended to give more preventive advice.There was insufficient information regarding the cost-effectiveness of the different remuneration methods. AUTHORS' CONCLUSIONS Financial incentives within remuneration systems may produce changes to clinical activity undertaken by primary care dentists. However, the number of included studies is limited and the quality of the evidence from the two included studies was low/very low for all outcomes. Further experimental research in this area is highly recommended given the potential impact of financial incentives on clinical activity, and particular attention should be paid to the impact this has on patient outcomes.
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Affiliation(s)
- Paul Brocklehurst
- School of Dentistry, The University of ManchesterCoupland III BuildingOxford RoadManchesterUKM13 9PL
| | - Juliet Price
- The University of ManchesterSchool of DentistryManchesterUK
| | - Anne‐Marie Glenny
- School of Dentistry, The University of ManchesterCochrane Oral Health GroupCoupland III Building, Oxford RoadManchesterUKM13 9PL
| | - Martin Tickle
- School of Dentistry, The University of ManchesterCoupland III BuildingOxford RoadManchesterUKM13 9PL
| | - Stephen Birch
- Faculty of Health Sciences, McMaster UniversityCentre for Health Economics and Policy Analysis, Department of Clinical Epidemiology and Biostatistics1280 Main Street WestHamiltonCanadaL8S 4K1
| | - Elizabeth Mertz
- San Francisco School of Dentistry, University of CaliforniaPreventative and Restorative Dental Sciences, Suite 4103333 California StreetSan FranciscoUSACA 94118
| | - Jostein Grytten
- University of OsloDepartment of Community DentistryBox 1052BlindernOsloNorway0316
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Brocklehurst P, Birch S, McDonald R, Tickle M. Determining the optimal model for role-substitution in NHS dental services in the United Kingdom. BMC Oral Health 2013; 13:46. [PMID: 24063247 PMCID: PMC3849722 DOI: 10.1186/1472-6831-13-46] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Accepted: 09/13/2013] [Indexed: 12/01/2022] Open
Abstract
Background Role-substitution describes a model of dental care where Dental Care Professionals (DCPs) provide some of the clinical activity previously undertaken by General Dental Practitioners. This has the potential to increase technical efficiency, the capacity to care and reduce costs. Technical efficiency is defined as the production of the maximum amount of output from a given amount of input so that the service operates at the production frontier i.e. optimal level of productivity. Academic research into technical efficiency is becoming increasingly utilised in health care, although no studies have investigated the efficiency of NHS dentistry or role-substitution in high-street dental practices. The aim of this study is to examine the barriers and enablers that exist for role-substitution in general dental practices in the NHS and to determine the most technically efficient model for role-substitution. Methods/design A screening questionnaire will be sent to DCPs to determine the type and location of role-substitutive models employed in NHS dental practices in the United Kingdom (UK). Semi-structured interviews will then be conducted with practice owners, DCPs and patients at selected sites identified by the questionnaire. Detail will be recorded about the organisational structure of the dental team, the number of NHS hours worked and the clinical activity undertaken. The interviews will continue until saturation and will record the views and attitudes of the members of the dental team. Final numbers of interviews will be determined by saturation. The second work-stream will examine the technical efficiency of the selected practices using Data Envelopment Analysis and Stochastic Frontier Modeling. The former is a non-parametric technique and is considered to be a highly flexible approach for applied health applications. The latter is parametric and is based on frontier regression models that estimate a conventional cost function. Discussion Maximising health for a given level and mix of resources is an ethical imperative for health service planners. This study will determine the technical efficiency of role-substitution and so address one of the key recommendations of the Independent Review of NHS dentistry in England.
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Affiliation(s)
- Paul Brocklehurst
- School of Dentistry, The University of Manchester, Oxford Road, Manchester, UK.
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Tickle M, Campbell S. How do we measure quality in primary dental care? Br Dent J 2013; 215:183-7. [DOI: 10.1038/sj.bdj.2013.789] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2013] [Indexed: 11/09/2022]
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Tickle M. Revolution in the provision of dental services in the UK. Community Dent Oral Epidemiol 2012; 40 Suppl 2:110-6. [DOI: 10.1111/j.1600-0528.2012.00729.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Martin Tickle
- Dental Public Health and Primary Care, School of Dentistry; The University of Manchester; Manchester; UK
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