The potential of the Child Health Utility 9D Index as an outcome measure for child dental health

Economic evaluation of a water fluoridation scheme in Cumbria, UK

OBJECTIVES

The addition of fluoride to community drinking water supplies has been a long-standing public health intervention to improve dental health. However, the evidence of cost-effectiveness in the UK currently lacks a contemporary focus, being limited to a period with higher incidence of caries. A water fluoridation scheme in West Cumbria, United Kingdom, provided a unique opportunity to study the contemporary impact of water fluoridation. This study evaluates the cost-effectiveness of water fluoridation over a 5-6 years follow-up period in two distinct cohorts: children exposed to water fluoridation in utero and those exposed from the age of 5.

METHODS

Cost-effectiveness was summarized employing incremental cost-effectiveness ratios (ICER, cost per quality adjusted life year (QALY) gained). Costs included those from the National Health Service (NHS) and local authority perspective, encompassing capital and running costs of water fluoridation, as well as NHS dental activity. The measure of health benefit was the QALY, with utility determined using the Child Health Utility 9-Dimension questionnaire. To account for uncertainty, estimates of net cost and outcomes were bootstrapped (10 000 bootstraps) to generate cost-effectiveness acceptability curves and sensitivity analysis performed with alternative specifications.

RESULTS

There were 306 participants in the birth cohort (189 and 117 in the non-fluoridated and fluoridated groups, respectively) and 271 in the older school cohort (159 and 112, respectively). In both cohorts, there was evidence of small gains in QALYs for the fluoridated group compared to the non-fluoridated group and reductions in NHS dental service cost that exceeded the cost of fluoridation. For both cohorts and across all sensitivity analyses, there were high probabilities (>62%) of water fluoridation being cost-effective with a willingness to pay threshold of £20 000 per QALY.

CONCLUSIONS

This analysis provides current economic evidence that water fluoridation is likely to be cost-effective. The findings contribute valuable contemporary evidence in support of the economic viability of water fluoridation scheme.

Parent-Reported Child and Parent Quality of Life during COVID-19 Testing at an Australian Paediatric Hospital Outpatient Clinic: A Cross-Sectional Study

Globally, we have seen a drop in adult and child quality of life (QOL) during the COVID-19 pandemic. However, little is known about adult or child QOL during the height of the pandemic in Australia and the impact of government-imposed restrictions, specifically attending school on-site versus home schooling. Our study aimed to establish if QOL in children and parents presenting to a Respiratory Infection Clinic in Victoria, Australia, for COVID-19 PCR testing differed from pre-pandemic population norms. We also explored whether on-site versus home schooling further impacted QOL. Following the child's test and prior to receiving results, consenting parents of children aged 6 to 17 years old completed the Child Health Utility 9 Dimension (CHU9D) instrument on their child's behalf. Parents of children aged birth to five years completed the EuroQOL 5-Dimension 5-Level (EQ-5D-5L) instrument on their own behalf (cross-sectional study). Data analyses utilised quantile regression, adjusting for the child's age, COVID-19 symptoms, gender and chronic health conditions. From July 2020 to November 2021, 2025 parents completed the CHU9D; the mean age for children was 8.41 years (±3.63 SD), and 48.4 per cent were female (n = 980/2025). In the same time period, 5751 parents completed the EQ-5D-5L; the mean age for children was 2.78 years (±1.74 SD), and 52.2 per cent were female (n = 3002/5751). Results showed that QOL scores were lower than pre-pandemic norms for 68 per cent of the CHU9D group and 60 per cent of the EQ-5D-5L group. Comparing periods of on-site to home schooling, there was no difference between the median QOL scores for both CHU9D (0.017, 95% CI -0.05 to 0.01) and EQ-5D-5L (0.000, 95% CI -0.002 to 0.002). Our large-scale study found that while QOL was reduced for children and parents at the point of COVID-19 testing during the pandemic, differing levels of government-imposed restrictions did not further impact QOL. These unique insights will inform decision-making in relation to COVID-19 and future pandemics.

Psychometric Properties of Generic Preference-Weighted Measures for Children and Adolescents: A Systematic Review

INTRODUCTION

Preference-weighted measures (PWMs)-also referred to as preference-based measures in the literature-of health status/health-related quality of life plays an essential role in estimating quality-adjusted life-years (QALY) for use in economic evaluations of healthcare products and interventions. However, as PWMs are first and foremost intended to accurately reflect respondent health status, they should ideally demonstrate good psychometric properties for the population in question. This study aimed to systematically review published evidence on the measurement properties of commonly used PWMs for children and adolescents.

METHODS

Three electronic databases (PubMed, Medline, and PsycINFO) were searched for articles assessing the psychometric properties (content validity, construct validity-including convergent validity and known-group validity, test-retest reliability, and responsiveness) of the PWMs of interest (AQoL-6D, CHU9D, HUI2, HUI3, and EQ-5D-Y). The COsensus-based Standards for the selection of health Measurement INstruments methodology (COSMIN) guidelines were used to assess (a) the methodological quality of the studies included and (b) the psychometric performance of the instruments covered. Data were analysed overall as well as by population (country and disease group) and perspective (self-report or proxy-report). The study protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO) database (CRD42021277296).

RESULTS

In total, 53 articles were included in this systematic review. Health Utilities Index (HUI) was tested only in patient populations, CHU9D was most frequently tested in general population samples, while EQ-5D-Y was tested in both populations. Overall, there was high-quality evidence supporting sufficient construct validity for all instruments except AQoL-6D. Evidence supporting test-retest and responsiveness was scarce. There was high-quality evidence supporting sufficient responsiveness of HUI2 and HUI3, and inconsistent test-retest reliability of CHU9D and EQ-5D-Y. Evidence for content validity was minimal and therefore not extracted and synthesized for any PWMs.

CONCLUSION

This review provides updated evidence on the measurement properties of existing generic PWMs for children and adolescents. High-quality evidence for all relevant psychometric properties and across a range of populations was not available for any of the instruments included, indicating that further work is needed in this direction. This study has identified some of the most noticeable evidence gaps for each of the individual measures. Users can use this information to guide their decision on the choice of PWM to administer.

Cost-effectiveness of scar management post-burn: a trial-based economic evaluation of three intervention models

Optimal burn scar management has the potential to markedly improve the lives of children, but can require substantial healthcare resources. The study aimed to examine the cost-effectiveness of three scar management interventions: pressure garment; topical silicone gel; combined pressure garment and topical silicone gel therapy, alongside a randomised controlled trial of these interventions. Participants were children (n = 153) referred for burn scar management following grafting, spontaneous healing after acute burn injury, or reconstructive surgery. Healthcare resource use was costed from a health service perspective (6-months post-burn time-horizon). The mean total scar management cost was lowest in the topical silicone gel group ($382.87 (95% CI $337.72, $443.29)) compared to the pressure garment ($1327.02 (95% CI $1081.46, $1659.95)) and combined intervention $1605.97 ($1077.65, $2694.23)) groups. There were no significant between-group differences in Quality Adjusted Life Year estimates. There was a 70% probability that topical silicone gel dominated pressure garment therapy (was cheaper and more effective), a 29% probability that pressure garment therapy dominated combined therapy, and a 63% probability that topical silicone gel dominated combined therapy. In conclusion, topical silicone gel was the cheaper intervention, and may be favoured in the absence of clear clinical effect favouring pressure garment therapy or a combination of these management approaches.Trial registration: ACTRN12616001100482 (prospectively registered).

Economic evaluation of the Happy Talk pilot effectiveness trial: A targeted selective speech, language and communication intervention for children from areas of social disadvantage

Purpose: This study presents a cost-effectiveness analysis of a targeted selective pre-school intervention programme, "Happy Talk", which focuses on language development, by simultaneously enhancing parental interaction and the pre-school environment.Method: Happy Talk (delivered to 77 children) is an add on intervention, and is compared to usual care, adopting a healthcare perspective. Cost-effectiveness analyses were carried out using the Pre-school Language Scale 5- Total (PLS-5) for baseline analysis and the Child Health Utility Instrument (CHU9D) in a secondary analysis.Result: Baseline cost-effectiveness analysis showed Happy Talk was more effective (6.3 point change in total PLS-5 standard score - effect size 0.463SD and more expensive (€82.06) than usual care (cost-effectiveness ratio is €13.02 per unit change). Employing a proxy to estimate monetary net benefit, the benefits outweigh the costs, showing that it is cost-effective. However, results do not persist when health-related quality of life outcome measures are considered.Conclusion: Findings suggest a targeted selective public health approach, could be considered value for money to reduce the societal burden of children with low levels of speech, language and communication. However, measurement of longer term outcomes and a larger trial are required, to definitively inform policy changes.

Adolescent valuation of CARIES-QC-U: a child-centred preference-based measure of dental caries

OBJECTIVES

This study develops an adolescent value set for a child-centred dental caries-specific measure of oral health-related quality of life (OHRQoL) based upon CARIES-QC (Caries Impacts and Experiences Questionnaire for Children). This study develops a new approach to valuing child health by eliciting adolescent preferences and anchoring these onto the 1-0 full health-dead QALY (quality adjusted life year) scale using ordinal adult preferences.

METHODS

Two online surveys were created to elicit preferences for the CARIES-QC classification system. The first comprised best-worst scaling (BWS) tasks for completion by adolescents aged 11-16 years. The second comprised discrete choice experiment tasks with a duration attribute (DCETTO) for completion by adults aged over 18 years. Preferences were modelled using the conditional logit model. Mapping regressions anchored the adolescent BWS data onto the QALY scale using adult DCETTO values, since the BWS survey data alone cannot generate anchored values.

RESULTS

723 adolescents completed the BWS survey and 626 adults completed the DCETTO survey. The samples were representative of UK adolescent and adult populations. Fully consistent and robust models were produced for both BWS and DCETTO data. BWS preferences were mapped onto DCETTO values, resulting utility estimates for each health state defined by the classification system.

CONCLUSION

This is the first measure with predetermined scoring based on preferences to be developed specifically for use in child oral health research, and uses a novel technique to generate a value set using adolescent preferences. The estimates can be used to generate QALYs in economic evaluations of interventions to improve children's oral health.

Clinical, individual and environmental factors related to children's health-related quality of life following treatment under general anaesthetic for dental caries: a path analysis

Objective

To examine the impact of clinical, individual, and environmental factors on children’s oral health-related quality of life (OHRQoL) and overall health-related quality of life (HRQoL) following dental caries management under general anaesthetic (GA).

Methods

Participants comprised 5- to 16-year-old children who were referred to a British Dental Hospital, for the management of their dental caries under GA. The Caries Impacts and Experiences Questionnaire for Children (CARIES-QC) and the Child Health Utility 9D (CHU9D) were used to assess child-reported OHRQoL and HRQoL, respectively, at baseline and 3-months follow up. A theoretical conceptual model, based on the Wilson and Cleary model of HRQOL, was evaluated using path analysis to explore indirect and direct relationships of the clinical, individual, and environmental variables on the quality of life outcomes following treatment.

Results

85 children completed the study. Path analyses revealed that 47% of the variance in OHRQoL scores was accounted for by the variables in the model. There were significant relationships between change in OHRQoL score and treatment type [extraction only vs. combination care (β = 1.41, p = 0.07)] and number of extractions (β = 0.46, p < 0.001). A higher number of tooth extractions was associated with poorer OHRQoL and HRQoL following treatment.

Conclusions

Treatment type, via number of extractions, may significantly impact on child OHRQoL and HRQoL following treatment under GA. However, to identify any other factors, that might affect these key outcomes, further enquiry is warranted with a bigger sample.

Development of a classification (descriptive) system for a preference-based quality of life measure for dental caries (dental caries utility index) among adolescents

OBJECTIVES

Preference-based quality-of-life measures (PBMs) have been developed in many clinical areas to aid estimation of more accurate utility values for economic evaluations. Existing oral health-related quality-of-life (OHRQoL) instruments are non-PBM and hence, cannot be used to generate utility values. The objective of this study was to develop a classification system for a new PBM (dental caries utility index-DCUI) for the most prevalent childhood oral health condition: dental caries.

METHODS

Possible domains and items to be included in the classification system were identified based on the reviewing available pediatric non-PBM OHRQoL instruments, studies eliciting utility values for oral health outcomes and clinical dentistry textbooks and based on the findings, a draft classification system was developed. To refine the draft classification system, semi-structured interviews were conducted among a convenience sample of 15 12-17-year-old adolescents who had experience with dental caries. The classification system was further refined and validated by a group of dental experts, using a modified Delphi technique.

RESULTS

The classification system comprised five items (pain/discomfort, difficulty in eating food/drinking, worried, ability to participate in activities, and appearance) and each item had a four-level response scale.

CONCLUSION

The classification system developed herein is considered an amenable tool for the subsequent development of a new PBM for dental caries. Once the scoring algorithm is completed, the classification system can be used to incorporate economic evaluations of dental caries health interventions.

CHU9D Normative Data in Peruvian Adolescents

BACKGROUND

Due to the vulnerability to protective and risk factors during adolescence, there is a growing interest in the study of health-related quality of life (HRQoL) at this stage. The CHU9D is a generic and practical HRQoL instrument that provides values on all dimensions of self-perceived health, in addition to providing utilities and a cost-utility assessment fee, unlike other instruments. This study was conducted with an adolescent population in Peru. The main objective of this article is to report the normative values of the CHU9D questionnaire in Peruvian adolescents.

METHODS

The CHU9D questionnaire was administered to Peruvian adolescent students. A total of 1229 young people participated in the survey. The CHU9D score was reflected as a function of gender, age, weight, height, and educational level.

RESULTS

The mean CHU9D utility index for the total sample was 0.890; this rating was significantly better for boys with 0.887 and girls with 0.867. The ceiling effect was higher for male adolescents with 32.6 than for female adolescents.

CONCLUSIONS

The results of the present study show that adolescents in school show a positive perception of HRQoL. It is also concluded that the CHU9D instrument can be effectively applied to economic evaluations for interventions to improve the quality of life of adolescents.

Demonstration of high value care to improve oral health of a remote Indigenous community in Australia

Background

The oral health of Indigenous children in remote communities is much worse than other population groups in Australia. Providing and maintaining an oral health service is challenging due to the remoteness of communities, the associated high cost, and the low retention of clinical staff. An annual preventive intervention delivered by fly-in clinicians may be a more cost-effective way to manage this problem. In this analysis we estimate the cost-effectiveness of an annual professional intervention for the prevention of dental caries in children of a remote Indigenous community in Far North Queensland.

Methods

A cost-effectiveness analysis was conducted based on an annual preventive intervention protocol. This included treating all dental decay in those with disease, applying fissure sealants, a disinfectant swab, fluoride varnish and providing oral hygiene instructions and dietary advice to all participating school children. This study included an intervention group and a natural comparison group and both groups were followed-up for 2 years after the initial preventive intervention. A Markov model was built to assess the cost-effectiveness of the intervention compared with the usual care. Costs of treatment from the Queensland Department of Health were used and effectiveness was measured as quality-adjusted life years (QALYs) with the CHU-9D. One-way and probabilistic sensitivity analyses were conducted to identify key drivers and quantify uncertainty.

Results

The preventive intervention was found to be highly cost-effective. The incremental cost per QALY gained was AU$3747. Probability of new caries and seeking treatment were identified as the main drivers of the model. In probabilistic sensitivity analysis intervention was cost effective in 100% of simulations.

Conclusion

An annual preventive intervention for remote Indigenous communities in Australia is a highly cost-effective strategy to prevent dental caries and improve the quality of life of children.

The Relationship between Caries-Specific Quality of Life and Generic Wellbeing in a Dutch Pediatric Population

Dental caries has significant negative impacts on the lives of children and young people. Whilst the impacts on children’s oral health-related quality of life (OHRQoL) have been increasingly investigated, the effect on children’s overall wellbeing remains largely unknown. Data were obtained from a survey conducted across four cities in the Netherlands. Children and their parents completed a series of questionnaires, which included Dutch versions of a caries-specific pediatric measure of OHRQoL (CARIES-QC-NL) and a generic pediatric health utility measure (CHU9D-NL). The participating children underwent dental examinations to determine their caries status. A total of 486 11-year-old children participated in the study, of which 184 had caries experience (38%). The mean number of decayed, missing and filled teeth (DMFT) was 0.71. The CARIES-QC-NL was found to have statistically significant correlations with the DMFT and CHU9D-NL. There were no statistically significant correlations between the CHU9D and the clinical variables. The CARIES-QC-NL had acceptable internal consistency and construct validity in this population despite the low prevalence of active caries. A relationship was demonstrated between OHRQoL and generic wellbeing in this population. Despite this, the CHU9D did not show any correlation with the clinical data, which may limit its application in studies of the impact of dental caries.

Pediatric Quality of Life Instruments in Oral Health Research: A Systematic Review

OBJECTIVE

To identify the generic or disease-specific pediatric quality of life (QoL) instruments used in oral health research among children and adolescents and to provide an overview of these QoL instruments.

METHODS

A systematic literature search was performed with multiple databases to identify the pediatric QoL instruments used in oral health research.

RESULTS

The literature search yielded 872 records; from these, 16 pediatric QoL instruments were identified that had been used among children and adolescents in oral health research. Of these, 11 were oral health-specific QoL instruments and five were generic instruments. Of the 11 oral health-specific QoL instruments, none were multiattribute utility instruments (MAUI), whereas of the five generic instruments, two (Child Health Utility 9D index and EuroQoL-5D youth) were classified as an MAUI. Except for one, all pediatric QoL instruments were published after the year 2000 and the majority originated from the USA (n = 8). Of the 11 oral health-specific QoL instruments, five instruments are designed for the respondent to be a child (i.e., self-report), one uses proxy responses from a parent or guardian, and five instruments have both self and proxy versions. Of the five generic QoL instruments, one uses proxy responses and the other four instruments have both self and proxy versions.

CONCLUSIONS

This review identified a wide variety of pediatric oral health-specific and generic QoL instruments used in oral health research among children and adolescents. The availability of these QoL instruments provides researchers with the opportunity to select the instrument most suited to address their research question.

Development and evaluation of CARIES-QC: a caries-specific measure of quality of life for children

BACKGROUND

Existing paediatric oral health-related quality of life (OHRQoL) measures are generic instruments designed to evaluate a range of oral conditions. It has been found that disease-specific measures may be more adept at detecting subtle changes which occur following treatment of the condition in question. Furthermore, existing self-report OHRQoL measures have not involved children at all stages of development of the measure. The aim of this study was to develop a caries-specific measure of quality of life for children.

METHODS

The first stage of the study involved a qualitative enquiry with children, aged 5-16 years, to inform the development of the measure. Children generated the potential items, contributed to item reduction and questionnaire design and participated in the testing of face and content validity. The resulting measure was evaluated in a cross-sectional validation study. Ethical approval was granted for the study.

RESULTS

The qualitative study found that children discussed a number of caries-related impacts which affected their daily lives. These were incorporated into a draft measure which was further refined following testing of face and content validity. This resulted in the production of the Caries Impacts and Experiences Questionnaire for Children (CARIES-QC), comprising 16 items and one global question. Two hundred participants with a mean (range) age of 8.1 (5-16) years took part in the further evaluation of CARIES-QC. Four items, which did not fit the Rasch model, were removed from further analysis. The remaining 12 items demonstrated good internal consistency (alpha = 0.9) and the total score showed significant correlations with the number of decayed teeth, presence of pain, pulpal involvement, the Child Perceptions Questionnaire (16-item short form) and the global score (p < 0.01, Spearman's rho).

CONCLUSION

In conclusion, children's input allowed the development of a valid and reliable child-centred caries-specific quality of life measure. CARIES-QC can now be used to evaluate which interventions for dental caries are most effective in reducing impacts from the child's perspective.

Evidence-Based Medicine in Otolaryngology Part 9: Valuing Health Outcomes

Decisions about resource allocation are increasingly based on value trade-offs between health outcomes and cost. This process relies on comprehensive and standardized definitions of health status that accurately measure the physical, mental, and social well-being of patients across disease states. These metrics, assessed through clinical trials, observational studies, and health surveys, can facilitate the integration of patient preferences into clinical practice. This ninth installment in the Evidence-Based Medicine in Otolaryngology Series is a practical overview of health outcome valuation, as well as the integration of both quality and quantity of life into standardized metrics for health research, program planning, and resource allocation. Tools for measuring preference-based health states, measures of effectiveness, and the application of metrics in economic evaluations are discussed.

Minimally Invasive Dentistry Based on Atraumatic Restorative Treatment to Manage Early Childhood Caries in Rural and Remote Aboriginal Communities: Protocol for a Randomized Controlled Trial

Background

The caries experience of Aboriginal children in Western Australia (WA) and elsewhere in Australia is more than twice that of non-Aboriginal children. Early childhood caries (caries among children <6 years) has a significant impact on the quality of life of children and their caregivers, and its management is demanding and commonly undertaken under general anesthesia. A randomized controlled trial using a minimally invasive dentistry approach based on Atraumatic Restorative Treatment (ART) in metropolitan Perth, WA, has demonstrated a significant reduction in the rate of referral to a dental specialist for dental care among children with early childhood caries, potentially reducing the need for treatment under general anesthesia. The tested approach was clinically successful and was without adverse effects on child dental anxiety. The model of ART-based primary care requires further testing and development if similar outcomes for Aboriginal children in remote and rural settings are to be achieved.

Objective

The study aims to develop, implement, and evaluate a remote primary care model to deliver effective primary dental services, encompassing treatment and preventive services, to Aboriginal preschool children (based on minimally invasive approaches including ART).

Methods

This is a two-arm parallel cluster randomized controlled study in which a test group will be provided with the intervention treatment at the start of the study and a control group will be provided with the intervention treatment 12 months after study commencement (delayed intervention). Participating communities, stratified by size of community (ie, number of children in the sample frame) and baseline caries experience, will be randomly assigned using a computer-generated block randomized list into immediate (test group) or delayed intervention (control group; provided with standard care). Informed consent will be obtained from all participants. Aboriginal research assistants will explain the study to the parents and assist the parents in completing the questionnaires. Participants in the randomized study will be examined at baseline and at 12 months follow-up by a calibrated examiner. Test group participants will subsequently be contacted and appropriate appointments coordinated for treatment. Control group participants will be provided with standard preventive care by the Aboriginal Health Workers and managed for treatment as per standard procedures.

Results

Community consultations have been undertaken and 26 communities have agreed to participate. Fieldwork is in progress to recruit study participants.

Conclusions

The significance of the study lies in its holistic approach to testing the model of care. Clinical evaluations as well as oral health‒related quality of life evaluations will be undertaken. Cost-effectiveness and cost-utility evaluations will assist in the development of policy options for oral health services for rural and remote communities. The elicitation of caregiver perspectives through focus group interviews will supplement the clinical, psychosocial, and cost-utility evaluations and provide a richer evaluation of the intervention.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12616001537448; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=371735 (Archived by WebCite at http://www.webcitation.org/70UMxndFZ)

Registered Report Identifier

RR1-10.2196/10322

Seal or Varnish? A randomised controlled trial to determine the relative cost and effectiveness of pit and fissure sealant and fluoride varnish in preventing dental decay

BACKGROUND

Fissure sealant (FS) and fluoride varnish (FV) have been shown to be effective in preventing dental caries when tested against a no-treatment control. However, the relative clinical effectiveness and cost-effectiveness of these interventions is unknown.

OBJECTIVE

To compare the clinical effectiveness and cost-effectiveness of FS and FV in preventing dental caries in first permanent molars (FPMs) in 6- and 7-year-olds and to determine their acceptability.

DESIGN

A randomised controlled allocation-blinded clinical trial with two parallel arms.

SETTING

A targeted population programme using mobile dental clinics (MDCs) in schools located in areas of high social and economic deprivation in South Wales.

PARTICIPANTS

In total, 1016 children were randomised, but one parent subsequently withdrew permission and so the analysis was based on 1015 children. The randomisation of participants was stratified by school and balanced for sex and primary dentition baseline caries levels using minimisation in a 1 : 1 ratio for treatments. A random component was added to the minimisation algorithm, such that it was not completely deterministic. Of the participants, 514 were randomised to receive FS and 502 were randomised to receive FV.

INTERVENTIONS

Resin-based FS was applied to caries-free FPMs and maintained at 6-monthly intervals. FV was applied at baseline and at 6-month intervals over the course of 3 years.

MAIN OUTCOME MEASURES

The proportion of children developing caries into dentine (decayed, missing, filled teeth in permanent dentition, i.e. D_4-6MFT) on any one of up to four treated FPMs after 36 months. The assessors were blinded to treatment allocation; however, the presence or absence of FS at assessment would obviously indicate the probable treatment received. Economic measures established the costs and budget impact of FS and FV and the relative cost-effectiveness of these technologies. Qualitative interviews determined the acceptability of the interventions.

RESULTS

At 36 months, 835 (82%) children remained in the trial: 417 in the FS arm and 418 in the FV arm. The proportion of children who developed caries into dentine on a least one FPM was lower in the FV arm (73; 17.5%) than in the FS arm (82, 19.6%) [odds ratio (OR) 0.84, 95% confidence interval (CI) 0.59 to 1.21; p = 0.35] but the difference was not statistically significant. The results were similar when the numbers of newly decayed teeth (OR 0.86, 95% CI 0.60 to 1.22) and tooth surfaces (OR 0.85, 95% CI 0.59 to 1.21) were examined. Trial fidelity was high: 95% of participants received five or six of the six scheduled treatments. Between 74% and 93% of sealants (upper and lower teeth) were intact at 36 months. The costs of the two technologies showed a small but statistically significant difference; the mean cost to the NHS (including intervention costs) per child was £500 for FS, compared with £432 for FV, a difference of £68.13 (95% CI £5.63 to £130.63; p = 0.033) in favour of FV. The budget impact analysis suggests that there is a cost saving of £68.13 (95% CI £5.63 to £130.63; p = 0.033) per child treated if using FV compared with the application of FS over this time period. An acceptability score completed by the children immediately after treatment and subsequent interviews demonstrated that both interventions were acceptable to the children. No adverse effects were reported.

LIMITATIONS

There are no important limitations to this study.

CONCLUSIONS

In a community oral health programme utilising MDCs and targeted at children with high caries risk, the twice-yearly application of FV resulted in caries prevention that is not significantly different from that obtained by applying and maintaining FSs after 36 months. FV proved less expensive.

FUTURE WORK

The clinical effectiveness and cost-effectiveness of FS and FV following the cessation of active intervention merits investigation.

TRIAL REGISTRATION

EudraCT number 2010-023476-23, Current Controlled Trials ISRCTN17029222 and UKCRN reference 9273.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 21. See the NIHR Journals Library website for further project information.

Economic evaluation of dental sealants: A systematic literature review

OBJECTIVES

To systematically review the literature on economic evaluations of dental sealants and examine the costs and effectiveness of caries prevention using sealants.

METHODS

Of 21 full-text articles examined, a total of 13 were included in this study. These studies are grouped by the type of intervention as follows: (i) sealants compared with no sealants; (ii) sealants compared with other forms of caries prevention; (iii) resin-based sealants compared with glass-ionomer sealants; (iv) different sealing strategies in primary teeth; (v) different sealing strategies in permanent teeth; and (vi) sealants based on school- or clinic-based setting of delivery. All currency is reported in constant 2010 US$.

RESULTS

Cost-effectiveness analyses differed due to varying study designs, assumptions, sealant delivery settings, outcomes, caries risk assessment and study durations. Findings varied on the cost-effectiveness of sealants compared with other caries-preventive strategies. Under the assumption of equal caries risk, always sealing primary molars appeared to be the most effective strategy, whereas risk-based sealing was the optimal strategy with differing caries risk. Studies that assessed sealing strategies in permanent teeth reported that risk-based sealing was more cost-effective than not sealing, but they differed on the cost-effectiveness of risk-based seal compared with non-risk-based seal. Sealants delivered in school settings had mixed results on costs but were as equally effective as sealants delivered in private practices.

CONCLUSIONS

The cost-effectiveness of sealants is dependent on the conditions of delivery. The list of cost-effectiveness ratios for each intervention can support policy makers to estimate expected returns on their investments in dental sealants.

A Review of the Development and Application of Generic Multi-Attribute Utility Instruments for Paediatric Populations

Multi-attribute utility instruments (MAUIs) are increasingly being used as a means of quantifying utility for the calculation of quality-adjusted life-years within the context of cost utility analysis. Traditionally, MAUIs have been developed and applied in adult populations. However, increasingly, researchers in health economics and other disciplines are recognising the importance of the measurement and valuation of health in both children and adolescents. Presently, there are nine generic MAUIs available internationally that have been used in paediatric populations: the Quality of Well-Being Scale (QWB), the Health Utility Index Mark 2 (HUI2), the HUI3, the Sixteen-dimensional measure of health-related quality of life (HRQoL) (16D), the Seventeen-dimensional measure of HRQoL (17D), the Assessment of Quality of Life 6-Dimension (AQoL-6D) Adolescent, the Child Health Utility 9D (CHU9D), the EQ-5D Youth version (EQ-5D-Y) and the Adolescent Health Utility Measure (AHUM). This paper critically reviews the development and application of the above nine MAUIs and discusses the specific challenges of health utility measurement in children and adolescents. Areas for further research relating to the development and application of generic MAUIs in paediatric populations are highlighted.

Can the Child Health Utility 9D measure be useful in oral health research?

BACKGROUND

Cost-utility analysis using the quality-adjusted life years (QALY) as an outcome measure to inform healthcare resource allocation is becoming more common. The Child Health Utility 9D (CHU9D) enables the calculation of utility values in children. Children were involved throughout its development to ensure it is child centred.

AIM

To determine whether the CHU9D is responsive to the changing components of the dmfs+DMFS index score in children receiving dental care over a 1-year period.

DESIGN

The study sample comprised children aged 6 to 9 years old who were enrolled in a split-mouth, placebo-controlled randomised controlled trial. All children had a comprehensive clinical examination including radiographs and health-related quality of life (HRQoL) was measured using the CHU9D at baseline and 1 year. Descriptive statistics was followed by bivariate analyses before effect sizes were calculated. A negative binomial model was fitted to assess whether the utility score predicted the components of decayed and filled teeth (combined primary and permanent teeth).

RESULTS

Eighty (92%) children completed the CHU9D at baseline and follow-up. They presented with a mean baseline d3mfs+D3MFS of 6.7 (SD = 7.1), which rose to 7.3 (SD = 7.0) at follow-up. The mean CHU9D score improved from 0.88 to 0.90 from baseline to follow-up. No statistically significant relationships were found between caries status and the CHU9D score.

CONCLUSION

The CHU9D was found to be unresponsive to the changing components of dental caries experience.

Assessing the Health-Related Quality of Life of Australian Adolescents: An Empirical Comparison of the Child Health Utility 9D and EQ-5D-Y Instruments

OBJECTIVES

To examine the performance of two recently developed preference-based instruments-the Child Health Utility 9D (CHU9D) and the EuroQol five-dimensional questionnaire Youth version (EQ-5D-Y)-in assessing the health-related quality of life (HRQOL) of Australian adolescents.

METHODS

An online survey including the CHU9D and the EQ-5D-Y, self-reported health status, and a series of sociodemographic questions was developed for administration to a community-based sample of adolescents (aged 11-17 years). Individual responses to both instruments were translated into utilities using scoring algorithms derived from the Australian adult general population.

RESULTS

A total of 2020 adolescents completed the online survey. The mean ± SD utilities of the CHU9D and the EQ-5D-Y were very similar (0.82 ± 0.13 and 0.83 ± 0.19, respectively), and the intraclass correlation coefficient (0.80) suggested good levels of agreement. Both instruments were able to discriminate according to varying levels of self-reported health status (P < 0.001). Although exhibiting good levels of agreement overall, some wide divergences were apparent at an individual level.

CONCLUSIONS

The study results are encouraging and illustrate the potential for both the CHU9D and the EQ-5D-Y to be more widely used for measuring and valuing the HRQOL of adolescent populations in Australia and internationally. Generating adolescent-specific scoring algorithms pertaining to each instrument and an empirical comparison of the resulting utilities is a natural next step. More evidence is required from the application of the CHU9D and the EQ-5D-Y in specific patient groups in adolescent health settings to inform the choice of instrument for measuring and valuing the HRQOL for the economic evaluation of adolescent health care treatments and services.

The validity of the Child Health Utility instrument (CHU9D) as a routine outcome measure for use in child and adolescent mental health services

BACKGROUND

Few cost-utility studies of child and adolescent mental health services (CAMHS) use quality adjusted life years (a combination of utility weights and time in health state) as the outcome to enable comparison across disparate programs and modalities. Part of the solution to this problem involves embedding preference-based health-related quality of life (PBHRQOL) utility instruments, which generate utility weights, in clinical practice and research. The Child Health Utility (CHU9D) is a generic PBHRQOL instrument developed specifically for use in young people. The purpose of this study was to assess the suitability of the CHU9D as a routine outcome measure in CAMHS clinical practice.

METHODS

Two hundred caregivers of children receiving community mental health services completed the CHU9D alongside a standardised child and adolescent mental health measure (the Strengths and Difficulties Questionnaire - SDQ) during a telephone interview. We investigated face validity, practicality, internal consistency, and convergent validity of the CHU9D. In addition, we compared the utility weights obtained in this group with utility weights from other studies of child and adolescent mental health populations.

RESULTS

Participants found the CHU9D easy and quick to complete. It demonstrated acceptable internal consistency, and correlated moderately with the SDQ. It was able to discriminate between children in the abnormal range and those in the non-clinical/borderline range as measured by the SDQ. Three CHU9D items without corollaries in the SDQ (sleep, schoolwork, daily routine) were found to be significant predictors of the SDQ total score and may be useful clinical metrics. The mean utility weight of this sample was comparable with clinical subsamples from other CHU9D studies, but was significantly higher than mean utility weights noted in other child and adolescent mental health samples.

CONCLUSIONS

Initial validation suggests further investigation of the CHU9D as a routine outcome measure in CAMHS is warranted. Further investigation should explore test-retest reliability, sensitivity to change, concordance between caregiver and child-completed forms, and the calibration of the utility weights. Differences between utility weights generated by the CHU9D and other utility instruments in this population should be further examined by administering a range of PBHRQOL instruments concurrently in a mental health group.