The cost-effectiveness of interleukin-1 genetic testing for periodontal disease

The promise and challenges of genomics-informed periodontal disease diagnoses

Recent advances in human genomics and the advent of molecular medicine have catapulted our ability to characterize human and health and disease. Scientists and healthcare practitioners can now leverage information on genetic variation and gene expression at the tissue or even individual cell level, and an enormous potential exists to refine diagnostic categories, assess risk in unaffected individuals, and optimize disease management among those affected. This review investigates the progress made in the domains of molecular medicine and genomics as they relate to periodontology. The review summarizes the current evidence of association between genomics and periodontal diseases, including the current state of knowledge that approximately a third of the population variance of periodontitis may be attributable to genetic variation and the management of several monogenic forms of the disease can be augmented by knowledge of the underlying genetic cause. Finally, the paper discusses the potential utility of polygenic risk scores and genetic testing for periodontitis diagnosis now and in the future, in light of applications that currently exist in other areas of medicine and healthcare.

The economic and societal impact of periodontal and peri-implant diseases

Periodontal and peri-implant diseases result from a chronic inflammatory response to dysbiotic microbial communities and are characterized by inflammation in the soft tissue and the ensuing progressive destruction of supporting bone, resulting in tooth or implant loss. These diseases' high prevalence, multifactorial etiology, extensive treatment costs, and significant detriment to patients' quality-of-life underscore their status as a critical public health burden. This review delineates the economic and sociocultural ramifications of periodontal and peri-implant diseases on patient welfare and healthcare economics. We delve into the implications of diagnosis, treatment, supportive care, and managing destructive tissue consequences, contrasting these aspects with healthy patients.

Economic Evaluations of Preventive Interventions for Dental Caries and Periodontitis: A Systematic Review

OBJECTIVES

To critically examine the methods used for full economic evaluations of preventive interventions for dental caries and periodontitis.

METHODS

Published literature post-2000 was searched to April 2021. Based on a developed intervention classification framework for dental caries and periodontitis, only universal, selective or indicated interventions were included in this review. The Drummond 10-point checklist was used for quality appraisal.

RESULTS

Of 3,007 unique records screened for relevance, 73 studies were reviewed. Most model-based studies (61/73) used cost-effectiveness analysis (49%) or cost-benefit analysis (28%). Trial-based studies (16/73) commonly used cost-effectiveness analysis (59%). Four studies used both economic evaluation methods. Sixty-four papers (88%) were on dental caries, eight papers (11%) focused on periodontitis, and one paper (1%) included both oral diseases; 72% of model-based and 82% of trial-based studies were of good quality. The most frequently investigated dental caries preventive interventions were water fluoridation (universal intervention; cost-saving or cost-effective), fissure sealant and fluoride varnish (selective and indicated interventions; cost-effectiveness outcomes were inconsistent). Supportive periodontal therapy with oral health education (indicated intervention; cost-effective) was the most frequently evaluated preventive intervention for periodontitis. Thirty percent of studies with a time horizon > 1 year did not apply an appropriate discount rate and 26% did not comprehensively discuss other important considerations beyond the technical analysis.

CONCLUSIONS

Generic health outcome measures should be incorporated for economic evaluations on preventive interventions for dental caries and periodontitis, and an increased focus to prevent periodontitis using economic evaluation methods is needed to inform resource allocation and policy decision-making.

Economic evaluations in the treatment and evaluation of patients with periodontal disease: A critical review

AIM

To evaluate the types and quality of reporting of economic evaluations carried out in the clinical management of periodontal disease over 32 years from 1987 to 2019.

MATERIAL AND METHODS

A systematic search of articles from 1987 to 2019 was conducted using PubMed, Web of Science, The Cochrane Central Register of Controlled Trials, Health Technology Assessment Database and Embase. The quality of the economic evaluations was assessed based on the Consolidated Health Economic Evaluation Reporting Standard checklist. Due to considerable between-study heterogeneity, a meta-analysis was not performed.

RESULTS

Twenty one publications were included. 11 studies used cost-effectiveness analysis, five used cost-minimization analysis, four used cost-utility analysis and two used cost-benefit analysis. Comparators, choice of health outcomes, estimating resources and costs were fully reported in all studies. Many studies had inadequate reporting in terms of estimating resources and costs, choice of health outcomes, characterizing heterogeneity and study perspective.

CONCLUSIONS

There has been an increase in health economics studies in the field of clinical periodontology over the past decade. Several studies did not report study perspective, and the health outcomes chosen were not relevant for some studies. Future studies should follow an economic evaluation checklist for high-quality reporting and consistency.

There is a paucity of economic evaluations of prediction methods of caries and periodontitis-A systematic review

Objectives

Direct cost for methods of prediction also named risk assessment in dentistry may be negligible compared with the cost of extensive constructions. On the other hand, as risk assessment is performed daily and for several patients in general dental practice, the costs may be considerable. The objective was to summarize evidence in studies of economic evaluation of prognostic prediction multivariable models and methods of caries and periodontitis and to identify knowledge gaps (PROSPERO registration number: CRD42020149763).

Material and methods

Four electronic databases (PubMed, Web of Science, The Cochrane Library, NHS Economic Evaluation Database) and reference lists of included studies were searched. Titles and abstracts were screened by two reviewers in parallel. Full‐text studies reporting resources used, costs and cost‐effectiveness of prediction models and methods were selected and critically appraised using a protocol based on items from the CHEERS checklist for economic evaluations and the CHARMS checklist for evaluation of prediction studies.

Results

From 38 selected studies, six studies on prediction fulfilled the eligibility criteria, four on caries and two on periodontitis. As the economic evaluations differed in method and perspective among the studies, the results could not be generalized. Our systematic review revealed methodological shortcomings regarding the description of predictive models and methods, and particularly of the economic evaluation.

Conclusions

The systematic review highlighted a paucity of economic evaluations regarding methods or multivariable models for prediction of caries and periodontitis. Our results indicate that what we currently practice using models and methods to predict caries and periodontitis lacks evidence regarding cost‐effectiveness.

Quality appraisal of economic evaluations done on oral health preventive programs-A systematic review

OBJECTIVES

If economic evaluations are to be used by decision makers, such evidence has to be robust so that the relevant policy maker use them. This study was undertaken with the purpose of identifying economic evaluations done on oral health preventive programs and to assess the standard of economic evidence in this field.

METHODS

A systematic search was conducted using four major electronic databases in order to search for economic evaluations done on oral health preventive programs. This included economic evaluations that were published between January 1975 and May 2018 on preventive interventions for periodontal disease, oral cancer screening, and other common oral health conditions. To avoid duplications with previous studies, for dental caries interventions, this review included studies from April 2012 and May 2018. "Guidance to undertaking reviews in health care," developed by York University, was used to assess the quality of reporting in the evaluations, using which strengths and shortcomings were identified.

RESULTS

A total of 2026 records were initially found. After title and abstract screening, and elimination by full text review, 33 relevant economic evaluations were identified. Majority of the economic evaluations included were conducted on dental caries prevention; a few were done on oral cancer screening, periodontal disease, and general preventive dentistry (health promotion, oral hygiene etc.).

CONCLUSIONS

In comparison to the findings observed in previous reviews, there has been improvements in the quality of reporting in economic evaluations. Several areas still in need for improve were identified (e.g., productivity costs, currency and prices, and generalizability issues).

Predictors for tooth loss in periodontitis patients: Systematic review and meta-analysis

AIM

A range of predictors for tooth loss in periodontitis patients have been reported. We performed a systematic review and meta-analysis to assess the consistency and magnitude of any association between a total of 12 predictors and tooth loss.

MATERIALS AND METHODS

Medline/Embase/Central were searched for longitudinal studies investigating the association between predictors and tooth loss in periodontitis patients. Random-effects meta-analysis was performed, and study quality assessed.

RESULTS

Twenty studies (15,422 patients, mean follow-up: 12 years) were included. The mean annual tooth loss/patient was 0.12 (min./max: 0.01/0.36). Older patients (n = 8 studies; OR: 1.05, 95% CI: 1.03-1.08/year), non-compliant ones (n = 11; 1.51, 1.06-2.16), diabetics (n = 7; 1.80, 1.26-2.57), those with IL-1-polymorphism (n = 3; 1.80; 1.29-2.52) and smokers (n = 15; 1.98, 1.58-2.48) had a significantly higher risk of tooth loss. Teeth with bone loss (n = 3; 1.04, 1.03-1.05/%), high probing pocket depth (n = 6; 3.19, 1.70-5.98), mobility (n = 4; 3.71, 1.65-8.38) and molars (n = 4; 4.22, 2.12-8.39), especially with furcation involvement (n = 5; 2.68, 1.75-4.08) also showed higher risks. Gender (n = 16; 0.95, 0.86-1.05) and endodontic affection (n = 3; 3.62, 0.99-13.2) were not significantly associated with tooth loss.

CONCLUSIONS

Older, non-compliant, smoking or diabetic patients, and teeth with bone loss, high probing pocket depth, mobility, or molars, especially with furcation involvement showed higher risks of tooth loss.

Is individualized medicine more cost-effective? A systematic review

BACKGROUND

Individualized medicine (IM) is a rapidly evolving field that is associated with both visions of more effective care at lower costs and fears of highly priced, low-value interventions. It is unclear which view is supported by the current evidence.

OBJECTIVE

Our objective was to systematically review the health economic evidence related to IM and to derive general statements on its cost-effectiveness.

DATA SOURCES

A literature search of MEDLINE database for English- and German-language studies was conducted.

STUDY APPRAISAL AND SYNTHESIS METHOD

Cost-effectiveness and cost-utility studies for technologies meeting the MEDLINE medical subject headings (MeSH) definition of IM (genetically targeted interventions) were reviewed. This was followed by a standardized extraction of general study characteristics and cost-effectiveness results.

RESULTS

Most of the 84 studies included in the synthesis were from the USA (n = 43, 51 %), cost-utility studies (n = 66, 79 %), and published since 2005 (n = 60, 71 %). The results ranged from dominant to dominated. The median value (cost-utility studies) was calculated to be rounded $US22,000 per quality-adjusted life year (QALY) gained (adjusted to $US, year 2008 values), which is equal to the rounded median cost-effectiveness in the peer-reviewed English-language literature according to a recent review. Many studies reported more than one strategy of IM with highly varying cost-effectiveness ratios. Generally, results differed according to test type, and tests for disease prognosis or screening appeared to be more favorable than tests to stratify patients by response or by risk of adverse effects. However, these results were not significant.

LIMITATIONS

Different definitions of IM could have been used. Quality assessment of the studies was restricted to analyzing transparency.

CONCLUSIONS

IM neither seems to display superior cost-effectiveness than other types of medical interventions nor to be economically inferior. Instead, rather than 'whether' healthcare was individualized, the question of 'how' it was individualized was of economic relevance.

Markov models in dentistry: application to resin-bonded bridges and review of the literature

Markov models are mathematical models that can be used to describe disease progression and evaluate the cost-effectiveness of medical interventions. Markov models allow projecting clinical and economic outcomes into the future and are therefore frequently used to estimate long-term outcomes of medical interventions. The purpose of this paper is to demonstrate its use in dentistry, using the example of resin-bonded bridges to replace missing teeth, and to review the literature. We used literature data and a four-state Markov model to project long-term outcomes of resin-bonded bridges over a time horizon of 60 years. In addition, the literature was searched in PubMed Medline for research articles on the application of Markov models in dentistry.

Managing health care decisions and improvement through simulation modeling

Simulation modeling is a way to test changes in a computerized environment to give ideas for improvements before implementation. This article reviews research literature on simulation modeling as support for health care decision making. The aim is to investigate the experience and potential value of such decision support and quality of articles retrieved. A literature search was conducted, and the selection criteria yielded 59 articles derived from diverse applications and methods. Most met the stated research-quality criteria. This review identified how simulation can facilitate decision making and that it may induce learning. Furthermore, simulation offers immediate feedback about proposed changes, allows analysis of scenarios, and promotes communication on building a shared system view and understanding of how a complex system works. However, only 14 of the 59 articles reported on implementation experiences, including how decision making was supported. On the basis of these articles, we proposed steps essential for the success of simulation projects, not just in the computer, but also in clinical reality. We also presented a novel concept combining simulation modeling with the established plan-do-study-act cycle for improvement. Future scientific inquiries concerning implementation, impact, and the value for health care management are needed to realize the full potential of simulation modeling.

Cost effectiveness of pharmacogenomics: a critical and systematic review

The use of pharmacogenetic testing in clinical practice is limited thus far. A potential barrier to the widespread implementation of pharmacogenetic testing is the lack of evidence on whether testing provides good value for money. The objective of this review was to provide a systematic and critical review of economic evaluations of pharmacogenetic testing. A literature search using publically available databases was performed for articles published up to October 2009. To be included, studies had to meet the definition of being a pharmacogenomic study (defined as use of information on human genetic variation to target drug therapy) and an economic evaluation (defined as an evaluation of both costs and clinical outcomes). Articles that met these criteria were subsequently reviewed and graded using the Quality of Health Economic Studies (QHES) instrument. Lastly, the evidence for biomarker validity and utility were qualitatively assessed using expert opinion. A total of 34 articles were identified using our defined criteria. The most common disease category was thromboembolic-related diseases (26%), while the most common biomarkers were thiopurine methyltransferase and cytochrome P450 2C9 (18% each). Almost all studies were published after 2004 (91%). Two types of studies were identified: cost-effectiveness studies and cost-utility studies, with roughly half of the overall studies being cost-utility studies (53%) and a majority of these published within the last 3 years. The average quality score was 77 (range 29-99). Of the biomarkers reviewed, it was estimated that most had demonstrated clinical validity, but only two had demonstrated clinical utility. Despite a recent increase in the number of economic evaluations of pharmacogenetic applications, further studies examining the clinical validity and utility of these biomarkers are needed to support cost-effectiveness assessments.

The association of the composite IL-1 genotype with periodontitis progression and/or treatment outcomes: a systematic review

BACKGROUND

Genetically transmitted traits such as cytokine gene polymorphisms may accentuate the host inflammatory response to the bacterial challenge and influence susceptibility to periodontitis.

OBJECTIVE

To systematically review the evidence of an association between the interleukin-1 (IL-1) composite genotype, i.e. presence of the allele 2 in the gene clusters IL-1A-889 and in IL-1B +3953, and periodontitis progression and/or treatment outcomes.

MATERIAL AND METHODS

Based on the focused question, a search was conducted for longitudinal clinical trials comparing progression of periodontitis and/or treatment outcomes in IL-1 genotype-positive (carrying allele 2) and IL-1 genotype-negative (not carrying allele 2) subjects. A search in the National Library of Medicine computerized bibliographic database MEDLINE and a manual search were performed. Selection of publications, extraction of data and validity assessment were made independently by two reviewers.

RESULTS

The search provided 122 titles of which 11 longitudinal publications were included. The heterogeneity of the data prevented the performance of a meta-analysis. While findings from some publications rejected a possible role of IL-1 composite genotype on progression of periodontitis after various therapies, other reported a prognostic value for disease progression of the positive IL-1 genotype status. When assessed on a multivariate risk assessment model, several publications concluded that the assessment of the IL-1 composite genotype in conjunction with other covariates (e.g. smoking and presence of specific bacteria) may provide additional information on disease progression. The small sample size of the available publications, however, requires caution in the interpretation of the results.

CONCLUSION

Based on these findings, (i) there is insufficient evidence to establish if a positive IL-1 genotype status contributes to progression of periodontitis and/or treatment outcomes. Therefore, (ii) results obtained with commercially available tests should be interpreted with caution.

Current impact of gene technology on healthcare

OBJECTIVES

It has been claimed that gene technology will induce revolutionary changes in healthcare. This paper investigates how and to what extent these changes have been economically assessed.

METHODS

A generic framework was developed to distinguish between methodologically similar evaluations of healthcare technology. Methodological issues and the current state of economic evidence concerning human DNA technology were extracted from publications within these groups of evaluations.

RESULTS

Economic evaluations of "healthcare consisting of gene technology" were identified primarily for in vitro diagnostics for hereditary disease and others for pharmacogenetics and molecular pathology. "Healthcare enabled by gene technology" is far more encompassing and includes, e.g., biotechnology drugs for which various health economic evaluations can be found. Yet here, the impact of gene technology intertwines with the impact of other technologies and is therefore hardly susceptible to evaluation. The fields of evaluation may be classified best according to the two dimensions "purpose" and "stage of development". Current evaluations cover screening, diagnostic and treatment technologies in investigational, new and established stages. Apart from prenatal screening, healthcare consisting of gene technology was cost saving only for genotype tests replacing continuous phenotype tests and for one pharmacogenetic test. Conclusive evidence of favourable cost-effectiveness ratios is available only for few conditions.

CONCLUSION

Hypotheses about the impact of gene technology on healthcare must be explicit about the definition of "genetic" medicine. A general statement regarding healthcare enabled by gene technology is not possible. Based on current evidence, an era of healthcare consisting of gene technology built on widespread predictive testing is not desirable from a health economic viewpoint.

A framework to evaluate the economic impact of pharmacogenomics

INTRODUCTION

Pharmacogenomics and personalized medicine promise to improve healthcare by increasing drug efficacy and minimizing side effects. There may also be substantial savings realized by eliminating costs associated with failed treatment. This paper describes a framework using health claims data for analyzing the potential value of pharmacogenomic testing in clinical practice.

METHODS

We evaluated a model of alternate clinical strategies using asthma patients' data from a retrospective health claims database to determine a potential cost offset. We estimated the likely cost impact of using a hypothetical pharmacogenomic test to determine a preferred initial therapy. We compared the annualized per patient costs distributions under two clinical strategies: testing all patients for a nonresponse genotype prior to treating and testing none.

RESULTS

In the Test All strategy, more patients fall into lower cost ranges of the distribution. In our base case (15% phenotype prevalence, 200 US dollars test, 74% overall first-line treatment efficacy and 60% second-line therapy efficacy) the cost savings per patient for a typical run of the testing strategy simulation ranged from 200 US dollars to 767 US dollars (5th and 95th percentile). Genetic variant prevalence, test cost and the cost of choosing the wrong treatment are key parameters in the economic viability of pharmacogenomics in clinical practice.

CONCLUSIONS

A general tool for predicting the impact of pharmacogenomic-based diagnostic tests on healthcare costs in asthma patients suggests that upfront testing costs are likely offset by avoided nonresponse costs. We suggest that similar analyses for decision making could be undertaken using claims data in which a population can be stratified by response to a drug.

Application of nonhomogenous Markov models for analyzing longitudinal caries risk

OBJECTIVES

Markov modeling is a useful mathematical procedure for calculating probabilities of disease prognosis. Increasingly, Markov models are being applied in medical and health services research and also in social sciences research. The purpose of our study was to use the Markov process to determine time-dependent transition probabilities for caries-free children to convert to a caries-active state and to assess the impact of salivary mutans streptococci (MS) levels on caries status.

METHODS

Our analysis was based on data obtained from a 6-year longitudinal study of risk factors associated with caries onset in children.

RESULTS

Based on a two-state Markov model, the probability that a caries-free child would convert to a caries-active state during the study ranged between 0.0046 and 0.0471. The highest probability of converting from a caries-free state to a caries-active state was 0.0471 at age 8.5 years.

CONCLUSIONS

In addition to standard statistical methods of analyzing longitudinal caries data, Markov models show promise for use in the analysis of caries risk.

Economic analyses of human genetics services: a systematic review

PURPOSE

The study's purpose was to conduct a structured review of economic analyses of genetic services. These will be increasingly valuable tools for assessing the clinical and economic outcomes of new medical technologies.

METHODS

We searched for economic studies published between January 1990 and August 2004 from a variety of publicly available databases. Articles were first reviewed to determine whether they were original studies, and second to determine whether they were formal cost-effectiveness analyses by established criteria. Articles meeting these criteria were graded using a validated rating scale.

RESULTS

Of 149 articles, 63 met established criteria for cost-effectiveness analyses. The majority (87%) were published since 1996. The majority of studies considered adult (31) or prenatal (25) conditions with the remainder considering preconception or pediatric conditions. More than half used life years gained or an ad hoc measure of outcome (e.g., cases detected). Twenty-five percent measured outcome as quality-adjusted life years. The disease areas most considered were cancer (21%) and aneuploidies (18%). The average quality ranking was 87 of 100 possible (range 48-100). Common shortcomings included lack of statement of perspective, lack of discussion of potential bias, and lack of disclosure of funding sources.

CONCLUSIONS

Relatively few economic evaluations are available for genetic services, and most are clustered in specific disease areas. Overall quality was high, but varied widely. Most shortcomings that would improve study quality are easy to address. To improve the relevance of these studies, researchers need to incorporate measures of outcome that are familiar to decision makers, including quality-adjusted life years.

Genetic health technology and economic evaluation: a critical review

The aim of the review is to establish whether, on the basis of previous published evidence, current accepted guidance for health economic evaluation needs to be adapted to evaluate healthcare based on use of genetic information. Online literature search strategies were designed (using PubMed and the NHS Economic Evaluation Database [NHS EED], among others) to gather papers carrying out or discussing economic evaluation and genetics. Papers meeting the inclusion criteria were obtained and reviewed. The papers purporting to be economic analyses were classified using the criteria of the NHS EED and the British Medical Journal (BMJ) working party on peer review of health economic literature. Of 120 English-language papers that met the criteria for review, only 37 were economic evaluations according to the criteria set out by the NHS EED and BMJ working party on economic evaluations. Of these 37, only 33 papers discussed economic evaluation methodologies in the genetics context. The economic evaluation papers did not seem to tackle any of the problems discussed in the methodological papers. Economic evaluation methods offer a structured approach for evaluation of changes but may need to change in order to assess the new technologies. We have found that such studies have not been widely reported, and that those that have been reported do not depart from current economic methods. We have identified a need for better skills and guidance in health economics within this growing area of research.

Cost-benefit, cost-effectiveness and cost-utility analyses of periodontitis prevention

OBJECTIVE

The aim of this paper was to determine whether there is evidence that periodontitis prevention is economically justified.

MATERIAL AND METHODS

The characteristics of economic assessments such as cost-benefit, cost-effectiveness and cost-utility analyses were first derived from the literature on health economy. A literature search was conducted using PubMed up to December 2004. Inclusion criteria required that economic analyses be based on scientific principles including a hypothesis, valid comparative groups as well as a cost/benefit, cost/effectiveness and cost/utility assessment.

RESULTS

Only 14 papers were located, which included, in the broadest sense, economic parameters. From these papers, three were systematic reviews, three were randomized controlled studies, four were controlled studies, one was a longitudinal cohort study and three papers were based on statistical modelling. Only one paper reported actual costs for periodontal and dental treatment. Extensive programmes aimed at prevention of periodontal disease in a general population group showed no economic benefit. Adjunctive genetic/and or microbiological testing likewise showed no economic benefit. Economic assessments and real costs are not generally available in the literature. Statistical modelling suggested that non-surgical periodontal procedures are more economical compared with surgical interventions. The use of local delivery devices as an adjunct to Sc/RP showed no economic advantage.

CONCLUSION

It is suggested that economic parameters as well as patient-centred outcomes be included in clinical trials. These data are essential for the appropriate allocation of resources for preventive measures on an individual patient and population base.

An introduction to cost-effectiveness and cost-benefit analysis of pharmacogenomics

Methods of economic evaluation, especially cost-effectiveness analysis and cost-benefit analysis, are widely used to examine new healthcare technologies. However, few economic evaluations of pharmacogenomics have been conducted, and pharmacogenomic researchers may be unfamiliar with how to review or conduct these analyses. This review provides an overview of the methods of economic evaluation and examples of where they have been applied to pharmacogenomics. We discuss the steps in conducting a cost-effectiveness or cost-benefit analysis, demonstrating these steps using specific examples from the pharmacogenomics literature.