Transcript Slide 1

Ryan White CARE Act Title I
Dental Impact Evaluation and
Cost Effectiveness
Julia Hidalgo, ScD, MSW, MPH
Amanda Benedict, MA
Positive Outcomes, Inc.
Carol M. Stewart, DDS, MS
Department of Oral and Maxillofacial
Surgery and Diagnostic Sciences
University of Florida College of Dentistry
Acknowledgements
Stephen Abel, Julia Ali-John, Lidia
Alonso, Curtis Barnes, Debbie
Cochrane, Susan Dunmore, William
Green, Marlinda Quintana-Jefferson,
Sharanda Richardson, James Riley,
Sharon Rohoman, Michele Rosiere,
Rita Volpita, Deloris Williams,
Perminder Wadhwa, Marisol Hidalgo
No Broward
County
patients’ or
dental
providers’
images were
used in this
presentation
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Project Goals and Objectives
Determine the cost effectiveness of Broward County EMA
CARE Act Title I dental services
Compare Broward Title I with other EMAs to measure dental
expenditures, procedures covered, reimbursement rates, and
average costs of routine and specialty care
Determine cost and utilization by analyzing FY 2004-2005 claims
data
Evaluate the impact of dental services on HIV+ Broward County
residents
Use chart review to measure the extent to which standards and
outcomes were achieved
Use surveys and focus groups to determine client perceived
barriers to access and retention in dental care
Determine client perceived barriers accessing general and special
dental care
Determine overall effectiveness, as measured by client impact,
of dental services
Determine the relationship of cost effectiveness and client
outcomes in the EMA
Project Tasks
 Update literature review
Cost-effectiveness of HIV oral health
Best practices in delivering and
financing HIV oral health services
 Identify CARE Act grantees that fund HIV oral health services
Obtain information about their cost-effectiveness studies
Identify their best practices regarding delivering and
financing HIV oral health
 Measure the cost and utilization associated with Broward
County Title I-funded HIV clinics
 Conduct chart review at Title I-funded HIV clinics to assess the
extent to which standards and outcomes were achieved
 Determine the relationship between cost-effectiveness and
client outcomes associated with Title-I funded HIV clinics
 Assess HIV+ Broward County residents’ perceptions of
barriers to access and retention in HIV primary and specialty
oral health care
What are the benefits of
oral health treatment for
HIV+ patients?
Importance of HIV Oral
Health Care
 Oral conditions are important markers
in the clinical spectrum of HIV
infection
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Conditions such as aphthous ulceration and candidiasis indicate
acute seroconversion illness
Conditions such as candidiasis, hairy leukoplakia, KS, and
necrotizing and ulcerative gingivitis suggest HIV infection in
undiagnosed individuals
For those individuals in advancing stages of HIV infection,
candidiasis and hairy leukoplakia indicate clinical disease
progression and predict development of AIDS
Immune suppression in HIV+ individuals is associated with
candidiasis, necrotizing periodontal disease, long-standing herpes
infection, and major aphthous ulcers
Perinatally infected children have a greater rate of caries than their
siblings, particularly with advancing HIV disease
Due to the association between HIV infection and oral
conditions, CDC and other staging systems for HIV disease
progression include oral conditions
Importance of HIV Oral Health Care
 Early recognition and management of oral
conditions associated with HIV infection
are important in sustaining the health and
quality of life of HIV+ individuals
 Oral care early in the course of HIV infection can help to prevent
or slow wasting
 Access to oral care is important in aiding proper nutrition for HIV+
individuals
 With the advent of HAART, the ability to sustain proper nutrition
and to swallow medication is critical in achieving the optimal
benefit of HAART and adherence to medication regimens
 Among the almost oral conditions that can occur in HIV+
individuals
All of the conditions may be seen or palpated during physical
examination and produce subjective symptoms that are noticeable
Medication is effective in treating many of these conditions
 HAART treatment failure can be detected through dental exam
 HAB considers dental care to be so beneficial to HIV+ individuals
that it is considered a “core service”
Access to HIV Oral Health
Services is a National Problem
 Despite the importance of access to quality oral
care, large numbers of PLWH have an unmet
need for HIV oral health care
 Data from the longitudinal Health Care Services
Utilization Study (HCSUS) initiated in 1996
assessed barriers to accessing dental services
 Oral infections, mouth ulcers, and other severe dental
conditions associated with HIV infection are more than twice as
likely to go untreated as other HIV-related health problems
 Less than one-half (42%) of respondents had seen a dental
health professional in the preceding six months
 African-Americans, individuals whose exposure to HIV was
caused by hemophilia or blood transfusions, persons with less
education, and employed individuals were less likely to use
dental care than their counterparts
 19% of HIV-infected medical patients had perceived unmet need
for dental care in the last six months
Access to HIV Oral Health Services
is a National Problem
 Individuals most likely to have unmet dental
needs included Medicaid beneficiaries in
states without dental benefits, individuals
with no dental insurance, the very poor, and
individuals with less than a high school
education
 65% of respondents with a usual source of dental care had used
that service in the preceding six months
 Use of dental care was reported to be greatest among patients
obtaining dental care from an AIDS clinic (74%) and lowest
among individuals with no usual source of dental care (12%)
 Medicaid enrollees report significantly more unmet dental need
compared with privately insured patients
 14% of HIV patients had unmet dental needs in the six months,
compared to 9% of the general population
What is the HIV oral health
funding experience of other
CARE Act grantees?
Broward EMA ranks 11th among Title I EMAs in planned FY 2004 total
direct service funds allocated to dental services
EMA
Total FY 2004
Dental $
% Total FY 2004 Direct
Service $ to Dental
MAI FY 2004
Dental $
% Total FY 2004
MAI $ to Dental
Miami
$1,286,359
5.6%
$0
0.0%
Washington, DC
$1,144,437
5.1%
$39,300
3.4%
Chicago
$1,040,943
4.5%
$0
0.0%
Houston
$884,175
5.2%
$0
0.0%
Baltimore
$858,455
5.1%
$0
0.0%
Los Angeles
$841,290
2.7%
$39,002
4.6%
Atlanta
$824,882
4.8%
$0
0.0%
New York
$802,298
0.8%
$222,872
27.8%
San Francisco
$726,007
2.6%
$0
0.0%
Dallas
$700,482
6.0%
$0
0.0%
Ft. Lauderdale
$658,734
5.2%
$0
0.0%
Philadelphia
$653,156
3.0%
$0
0.0%
San Diego
$650,795
7.3%
$0
0.0%
Boston
$556,619
4.1%
$0
0.0%
Phoenix
$530,000
8.9%
$0
0.0%
Learning From Other
CARE Act Grantees
 POI contacted by telephone Title I and Title II
grantees spending over $500 K in direct
service funds for HIV dental services
Asked if they had assessed dental costeffectiveness, the methods used to pay for dental
services, and how services were organized
 Similarly, Dental Reimbursement Programs
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(DRPs) were contacted by email
Published articles and reports were searched
HAB dental expert also queried
Learning From Other
CARE Act Grantees
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No grantees contacted reported conducting costeffectiveness or cost-benefit studies related to the
HIV oral health services they purchased
Several approaches taken by Title I and Title II to
purchase dental services
University or community-based dental providers were
funded; grantees tend to have a small number of contractors
Tend to pay for general dental services, several also
purchase special dental services
Standard dental fee schedule, Medicaid payment rates (with
slightly higher payments), negotiated rates, “cost-based”
reimbursement, fund FTEs
Fee schedules variably updated
What is the
utilization
experience of
Title I-funded HIV
oral health
services and
related
expenditures?
Title I Funded HIV
Dental Clinics
Nova Southeastern
University College of
Dental Medicine, S
University Drive, Ft
Lauderdale
Paul Hughes Health
Center Dental Clinic, NW
6th Ave, Pompano Beach
Northwest Health Center
Dental Clinic, NW 15th
Way, Ft Lauderdale
Children’s Diagnostic
and Treatment Center
Dental Clinic, S Federal
Hwy, Ft Lauderdale
South Regional Health
Center Dental Clinic,
Pembroke Rd, Hollywood
Accessibility of Title I
Funded HIV Dental Clinics
 General dental clinic
services are geographically
accessible
Distributed throughout
Broward County
For the most part, they are
located near major freeways
and bus lines
 Specialty services are
available at Nova or
community-based dental
specialists
 Two of the five clinics are colocated with medical clinics
 NOVA is adding a new site
co-located at Center One
 Dental clinics do not have
evening appointments
HIV Dental Clinic Utilization
 2,738 HIV+ Broward County adult
residents received regular dental visits
at Title I-funded BCHD clinics between
December 2002 through June 2005
 This represents 25% of the estimated 10,748 HIV+
Broward County residents “in care”
 An average of 3.7 regular visits per adult patient
(median=3 visits), with total visits ranging from 1 to
31 visits
 363 HIV+ Broward County residents received
specialty dental services, with an average of one visit
per patient
Total visits per patient ranged from 1 to 3 visits
 Inconsistent data coding and missing data prevented
analysis of differences in use or expenditures by age,
gender, race, ethnicity, income, or HIV dental clinic
Data were not transferred from dental records
What are the
expenditures
associated with
Title I-funded
regular and
specialty dental
services?
TYPE OF SERVICE
YEAR
REGULAR
2002
SPECIALTY
$930
2003
$624,803
$79,612
2004
$615,753
$128,013
2005
$237,221
$90,303
Payments through June 2005
 Title I paid $128 per regular dental visit during the study period
 An average of $526 was spent per patient during the study
period (median=$408), with expenditures ranging from $128 to
$4,237
 An average of $791 was spent per patient (median=$800) for
specialty dental services, with expenditures ranging from $42
to $8,050
Utilization patterns among adult BCHD HIV clinics patients reflect
availability of other funds to pay for dental services and the
impact of expanding dental contractors
Regular
Specialty
700
600
400
300
200
100
Jun-05
Apr-05
Feb-05
Dec-04
Oct-04
Aug-04
Jun-04
Apr-04
Feb-04
Dec-03
Oct-03
Aug-03
Jun-03
Apr-03
Feb-03
0
Dec-02
Total Visits
500
What are HIV+
Broward County
residents’
perceptions of
barriers to access
and retention in HIV
general and
specialty oral
health care?
Consumer feedback is being
sought through two methods
 A focus group will be convened on
February 22nd at 6 pm at BRHPC
HIV+ consumers receiving dental service
purchased by Title I, dental insurance, or other
mechanisms are encouraged to participate
Refreshments and compensation will be provided
Call Michelle Smith to sign up for the group
 A survey is being conducted via
Internet, paper survey, POI interview, or
case manager-assisted survey
Focus Group Questions
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Why is dental care important to HIV infected
Broward County residents?
To what extent are community dentists in
Broward County willing to treat HIV infected
adults? Children?
What barriers do HIV infected Broward County residents experience
in getting dental care from community dentists? Nova Dental School?
County-operated dental clinics?
To what extent does the cost of dental insurance act as a barrier to
HIV infected Broward County residents?
To what extent do out of pocket payments for dental care act as a
barrier to HIV infected Broward County residents?
How can access to HIV dental care in Broward County be improved?
What is the perception of HIV infected Broward County residents
about the quality of dental care they receive?
In what ways can the quality of HIV dental care in Broward County be
improved?
Survey Design
 A convenience sample of HIV+ Broward
County residents is being used due to
absence of systematic gathered data to
identifying survey subjects
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Flyers were posted at all Broward County HIV counseling and
testing, treatment, case management, and support programs
1,000 individual postcards about the survey are being distributed
at these sites
The Planning Council and Committees were notified about the
survey
The Case Management Network was notified about the survey
The survey’s design is based on HCSUS, a federally-funded
nationally representative survey of HIV+ adults initiated in 1996
National results are available to serve as benchmark data via
special analysis being conducted by federal researchers
Surveys may be completed via Internet, by telephone, via case
managers’ assistance, or by paper survey
12 surveys had been submitted by February 10th
What is the
quality of
dental
services
provided by
Broward
County Title Ifunded dental
clinics?
Chart Review Process
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POI entered into a Business Associates
Agreement to be allowed to do chart review
The dental standards were reviewed to
design the chart review form; with additional
items added by Dr. Stewart, the project’s
dental consultant
Study period: March 2004 – February 2005
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 Reviews were conducted at three of the four BCHD HIV dental
clinics: Paul Hughes HC, Northwest HC, South Regional HC
 Charts were not reviewed at CDTC (only 12 patients in the study
period) or Nova (not contracted during the study period)
 CHD staff created a data file containing records for 1,628 dental
patients served in the study period
 A random sample of the records was created to assist chart pull
by BCHD dental records staff; the first 45 charts on each
clinic’s random sample list
Chart Review Process
 A target of 30 randomly selected
charts was set per clinic to ensure
statistically significant, generalizable
results
 15 additional charts were randomly selected in case
charts were unavailable or the patient was treated
outside the study period
 Dr. Stewart and Dr. Hidalgo reviewed 92 charts
 Data were entered into an entry screen from the chart
 SPSS was used to analyze the chart data
 A draft report was prepared, with clinic-specific
findings noted
 The report findings were reviewed with BCHD staff;
with Dr. Stewart providing peer TA
 The final report provided summary findings, with
blinded results for the three individual clinics
Chart Review Items
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Intake form complete?
Name, SSN, address, birth date,
gender, race/ethnicity
Primary care MD’s name and contact
information complete?
HIV+ status, income, and Broward
County residency documented?
Emergency contact identified?
Signed consent for treatment?
Patient’s Rights Statement received
and HIPAA compliance documented?
Signed releases for all referrals made
and all disclosures of confidential
patient information to a third party?
Progress notes are current, legible,
signed, and dated?
Chart organized and orderly?
Progress notes address treatment
plan goals? Treatment plan, contains
measurable goals, objectives, and
time frames for achievement?
Treatment plan complies with
treatment guidelines?
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Is patient’s medical history
recorded and updated at least every
six months?
Allergies, special conditions,
current meds, CD4+ value,
white blood cell count, platelet
count, hepatitis C status, TB
status, medical clearance for
treatment?
Patient referred to specialist
documented?
Documentation of OI exam, soft
tissue exam, head and neck exam,
gingival and periodontal structure,
hard tissue?
Patient received preventive
education on oral techniques and
self-care?
If appropriate, patient received
nutrition counseling and tobacco
cessation counseling?
Chart Review Items
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Preventive fluoride program, if appropriate?
Is patient’s oral hygiene level noted?
Frequency of follow-up visits documented in the treatment
plan?
Was the dental note written?
Within 24 hours of the visit? Within 48 hours of the visit?
No documentation?
All dental notes appropriately signed?
Patients with more than one visit have a dental treatment
plan recorded in the dental record?
Patient will complete their initial treatment plan (Phase I)
within six months?
Discharge date and discharge plan follow-up or discharge
summary?
Procedures performed (surgical or routine extraction)?
X-ray of diagnostic quality?
Any complications?
Chart Review Findings:
Considerations for Dental
Record Staff
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Most dental charts recorded patient identifying information
All dental charts recorded patient name, Social Security number,
address, telephone number, and birth date
Primary care MD’s contact information was recorded in 85% of
charts
Documentation of income and Broward County residency was
included in almost all charts
Case management referral forms tended to be the source of
dental clinic referrals; these forms were not updated
Referral forms were not completed uniformly by the referring case
manager
Check off items, such as receipt of a signed release of patient
information, were not completed uniformly
No updated case management referral forms were included in
patient charts, including patients served for several years
12% of patients did not have emergency contact information
listed in their files
Most dental charts contained all of the relevant legal forms
Chart Review Findings:
Considerations for Dental Personnel
 All reviewed charts documented a treatment
plan with measurable goals, objectives, and a
timeframe for completion
 Medical history was recorded and updated at
six month intervals for almost all patients
Allergy information was noted in almost all charts, special
conditions were noted for 67% of patients, and current
medications were listed for 82% of patients
52% of dental charts included documentation of patients’
CD4+ values
Some charts contained CD4+ counts that were obtained one
to two years before the review period
Only 11% of dental charts included documentation of
Hepatitis C status; a question regarding Hepatitis C was not
included on the medical history form
Platelet and white blood cell count and TB infection status
were in almost all charts, as was medical clearance for dental
treatment
Chart Review Findings:
Considerations for Dental Personnel
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All treatment plans complied with published
treatment guidelines
Almost all progress notes addressed the treatment
plan goals
Less than one-half (44%) of all treatment plans’
progress notes met one or more of the “current,
legible, signed, and dated” criteria
Almost all charts documented OI exams, soft tissue
exams, head and neck exams, gingival and
periodontal structure exams, and hard tissue exams
Of the 21 patients who were referred to a specialist,
71% had referral follow-ups documented in their files
Chart Review Findings:
Considerations for Dental Personnel
 The level of oral hygiene was noted for most
patients
The dental hygienist seemed very conscientious in providing debridements,
appropriately recording the patient’s level of home care, and consistently
recording oral hygiene instruction provided to patients
 The treatment plan contained documentation of the frequency of
follow-up visits for almost all patients
 Dental notes were written and included in all dental charts, and
were written within 24 hours of the visit
However, complete signatures were not present on all dental notes; 78% of
dental notes were only initialed
 Almost all patients had more than one visit and had a treatment
plan noted in their dental records
77% of patients will have completed their initial treatment plan (Phase I)
within six months
 Nearly two-thirds (65%) of patients’ care ceased without formal
discharge from care
Patients tended to fail to return for care and no follow-up inquiry was
apparent
Chart Review Findings:
Considerations for Dental Personnel
 Extractions were noted in more than one-
third (35%) of charts, with 31% of these
patients (10 patients) having surgical
extractions and 75% having routine
extractions performed
 X-rays of diagnostic quality were present in 84% of dental charts
 No treatment-related complications were reported for any of the
charts reviewed
 Preventive education on oral techniques and self-care was
administered to 91% of patients
Inquiry about tobacco use was not included on the medical
history form; very low percentages of patients received
tobacco cessation counseling (7%)
Nutrition counseling did not appear to be a standard
practice and was not noted for any patients
How do the chart review findings compared to Title I standards?
Category
Morbidity
Treatment
adherence
Outcome
Patients
receive
preventive
care
Patients
complete
treatment
Indicator
Chart
Review
Finding
90% of patients are assessed for
opportunistic infections
98.9%
90% of patients receive soft tissue exam,
including perioral tissue and oral mucosa
98.9%
90% of patients receive exam of the
gingival and periodontal structures
96.7%
90% of patients receive preventive
education on oral techniques and self
care
91.1%
90% of patients with more than one visit
will have a dental treatment plan recorded
in the dental record
95.7%
70% of patients examined will have
completed their initial treatment plan
within six months
77.2%
How do the chart review findings compared to Title I standards?
Category
Indicator
Provider completes a
medical/dental history form in
initial visit
100% of patient charts
show complete
medical/dental history
Treatment plan is developed
based on the initial
comprehensive exam
100% of patients’ chart
have a treatment plan
Patient treatment plan is reviewed 100% of patients’ charts
and updated as necessary by the show review, as needed
dental provider
Chart
Review
Finding
95.7%
(medical)
100%
96.7%
Patients are referred to specialty
care in accordance with the
patients’ needs and treatment
plan
100% of patients’ charts
show referral to specialty
care for clients needing
this service
100%
Patients referred to specialty
services are followed-up
100% of patients’ charts
have documentation of
referral follow-up
71.4%
Recommendations
 Revise the patient intake form
 The conceptual approach to the treatment plan
and progress notes should be revised to better
capture temporal flow
 Record current or a past history of hepatitis C and
current or past history of hepatitis B infection
 Blood pressure readings should be a part of the baseline
medical history and should be added to the intake process
The accepted standard of care in dentistry is to take the patient’s
blood pressure at the initial appointment and at subsequent
appointments
This procedure can be done by a trained auxiliary
It is especially important before any procedures that utilize local
anesthetic, such as restorative, surgical, and some periodontal
procedures
 Tobacco cessation and nutritional counseling
The medical history should be modified to include those items
 The medical clearance form should include CD4+ count, along
with blood values for platelets, white blood cell count, and TB
Recommendations
 A review of the medical history immediately
before a dental extraction is important to help
avoid undesirable outcomes such as drug
interactions, prolonged bleeding, delayed healing,
or infections
 Such a review was recorded infrequently in
the treatment or progress notes associated
with dental extractions
 Although the charts reviewed documented that a gingival and
periodontal exam were completed, evidence of the results of
that exam was difficult to confirm
Infrequently a periodontal screening exam (PSR), or a
periodontal charting was found regarding attachment loss or
periodontal pockets, bleeding upon probing, or tooth
mobility
A periodontal diagnosis determined by the dentist, needed
to support the periodontal therapy provided, was not found
readily in the charts
Recommendations
 The majority of HIV seropositive patients report
discomfort from xerostomia (i.e., “dry mouth”)
 This is a condition makes chewing, swallowing,
and speaking more difficult, putting HIV
seropositive patients at much higher risk for
dental decay
 Consequently, it is very important for the dental team to suggest
ways to improve oral comfort through strategies to improve
salivary flow such as sugar free gums, lozenges, and fluids
 Efforts to minimize the patient’s susceptibility to dental decay
are also important
The dental team should encourage patients to use a fluoride
regimen appropriate for the particular individual
This might include an over-the-counter alcohol-free fluoride rinse,
fluoride home treatments, or prescription fluoride gels
 Documentation of these issues was absent from most charts. If
these concerns were discussed with patients, a chart entry
would be appropriate
Are dental
services
purchased with
Broward
County Title I
funds costeffective?
What are HAB’s expectations regarding
cost-effectiveness?
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Title I grantees should be able to compare the relative costs of
providing a specific service among different providers
This necessitates having service standards, service units,
and unit costs for each service
Quality of service is also a factor in determining cost
effectiveness and needs to be considered both in selecting
providers and in monitoring Quality Management programs
Planning councils need cost-effectiveness data to determine
how to prioritize services and allocate funds
This is closely tied to outcomes evaluation in that services
with better outcomes may be more costly but nonetheless
more cost effective when outcomes are considered
Also important to consider is the way services are provided
For example, bus passes may be cheaper but not as
effective in assuring access and maintenance in care as
taxi vouchers
Ryan White CARE Act Title I Manual
What are outcomes?
Outcomes are benefits or
results (positive or negative) for
clients that may occur during or
after program participation
Outcomes can be classified as
initial, intermediate, and longerterm based on how soon they
occur after program
participation begins
Ryan White CARE Act Title I Manual
Using HAB’s framework, what is known and unknown about the
cost-effectiveness of Title I- funded HIV oral health services?
TASK*
RESULT
Define and describe the service to be
assessed
Regular dental visit defined by Oral
Health Service Delivery Model:
Diagnostic, prophylactic, and
therapeutic services rendered by
dentists, dental hygienists, and
similar professional practitioners
Standards of care defined by Oral
Health Service Delivery Model
The cost of a dental visit is set as
$128 per general dental visit
Short-term outcomes associated
directly with Broward Title-I funded
dental services have been achieved.
It costs $128 in Title I oral health
funds to ensure that a patient
receives preventive oral health care
and completes treatment
Agree on the standards of care or
benchmarks related to service outcomes
Determine the unit or per-client costs of
these services
Determine the outcomes of the service
Describe the cost effectiveness of the
service in terms of a ratio of cost to attain a
specific outcome (e.g., it costs an average
of $846 in case management funds to
ensure that a client has obtained access to
specified core services)
* Ryan White CARE Act Title I Manual
What is cost-effectiveness analysis (CEA)?
 CEA compares the relative value of current versus new
strategies
 Commonly in CEA, a new strategy is compared with
current practice (the "low-cost alternative") to
calculate a math term, the cost-effectiveness (CE)
ratio:
 The result is the "price" of the additional outcome
purchased by switching from current practice to the
new strategy (e.g., $10,000 per life year). If the price
is low enough, the new strategy is considered "costeffective"
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How should we interpret the results of
cost-effectiveness analysis (CEA)?
CEA is only relevant to certain decisions
CEA is relevant only if a new strategy is both
more effective and more costly (or both less
effective and less costly)
If a strategy is cost-effective, the new
strategy is a good value.
It does not mean that the strategy saves
money
Just because a strategy saves money does
not mean that it is cost-effective
The concept of cost-effective requires a
value judgment—what you think is a good
price for an additional outcome, someone
else may not
Applying CEA to the Broward County Title I deliberations
regarding purchasing of dental services
From a CEA perspective, POI considered
whether the general and specialty dental
services are effective versus other dental
services
No other dental treatment modalities can be
substituted for the service now provided (i.e.,
there is no “new” service to substitute for
current dental practice)
This is similarly the case for the specialty services
purchased
Alternatively, non-dental services might be
substituted instead to address other clinical
and psychosocial service needs of patients
These services cannot address the oral health needs of
Broward County HIV+ indigent residents
Are dental
services
purchased with
Broward County
Title I funds costbeneficial?
What is cost-benefit analysis?
 A systematic quantitative method of
assessing the desirability of programs or
policies when it is important to take a
long view of future effects and a broad
view of possible side effects
Used to assess the costs versus the
benefits of a specific service or set of
services
A systematic quantitative method of assessing the desirability of
programs or policies when it is important to take a long view of
future effects and a broad view of possible side effects
Used to assess the costs versus the benefits of a specific service
or set of services
Allows policymakers and other stakeholders to weigh the benefits
versus the costs of various policy alternatives and identify the
trade-offs involved in funding one policy versus another
May express the point of view of a health care consumer, purchaser
of services (e.g., employer, health insurance plan, BCHSD
SAHCSD), service provider, or society
May be helpful to gaining an understanding of the personal, fiscal,
health care system, and societal impact of purchasing new services
or redistributing funds from existing services
Cost-Benefit Assessment: Key Concepts

Costs
Direct costs: expenses associated with
paying for a service (e.g., regular dental
visits)
Indirect costs: the cost not directly
attributable to the manufacturing of a product
Opportunity costs: the cost of passing up the
next best choice when making a decision
(e.g., the cost of purchasing dental services
versus another service category

Benefits
The directly measured dollar value of the tangible
benefits of goods or services
Indirectly measured dollar value of the tangible benefits
of good or services
Indirect benefits for which dollar value are not directly
measurable
Indirect benefits of oral health services
 Detection of HIV infection


associated with HIV infection
Reduce the presence of bacteria,
thus reducing strain on the
immune system
Dental exams can assist HIV
medical management
Detection of oral OIs and
other conditions may point to
HIV disease progression
HIV dental exams can be used
to detection OIs associated
with failure of HAART or lack
of adherence to HAART
Reduction of systemic
infections
patient
Identification of salivary
gland disease and oral warts
associated with HIV infection
Treat dry mouth associated
with antiretrovirals
 Treat conditions that exacerbate





wasting
Ensure that medication can be
swallowed
Treat conditions that inhibit
swallowing, chewing of food,
and speaking
Reduction or elimination of head
and neck pain
Reduce or delay disability
Improve quality of life
What are the
outcomes
associated with
dental services
purchased with
Broward County
Title I funds?
Measuring HIV Oral Health
Outcomes in Broward
County
Outcome measures to be
implemented in March 2006
Improved quality of life
Clients are made aware of the benefits of
participating in care by an oral health provider
Reduced incidence of oral opportunistic
infections
Slow periodontal disease progression
Healthier teeth and gums
Challenges Likely to be Encountered in
Measuring HIV Oral Health Outcomes in
Broward County
 Outcomes measurement requires planning for
detailed baseline and longitudinal data collection
 No baseline assessment of quality of life
undertaken at initiation of dental treatment
 How will changes in quality of life be assessed, particularly those
changes directly associated with oral health treatment?
 There is no systematic assessment of the baseline rates of oral
OIs, periodontal disease, or the health or teeth or gums among
HIV+ individuals treated in the Title-I funded system
Improvement relative to what?
 Inability to measure dental services outside of Title I-funded
system that may contribute to positive or negative outcomes
 Must accurately measure inpatient stays and count ambulatory
care visits for which oral health care was provided
 There is significant missing data regarding demographic, clinical,
smoking history, economic, health insurance, and other
characteristics associated with oral health outcomes
 Are you measuring actual outcomes or the quality of charting by
dental and other clinical personnel?
Challenges Likely to be Encountered in
Measuring HIV Oral Health Outcomes in
Broward County
 It is unclear if longitudinal clinical data can be
gathered routinely, inexpensively, and accurately
(e.g., PCIS)?
If not, chart review may add additional
expense
 How will the contribution of individual dental providers treating a
patient over time be taken into consideration in assessing long
term outcomes?
For example, how will differences in HIV training or supervision
be accounted for?
 Will the role of medical providers in treating oral OIs and educating
patients about the importance of dental care be assessed?
 How will the contribution of patients to their self care be assessed
at baseline and over time?
What about factors such as attitudes towards dental care, pain
phobia, health literacy, and beliefs about the benefits of dental
preventive services be taken into consideration?
 In measuring pediatric oral health outcomes, how will the role of
parents or guardians be taken into consideration?
Final Report
 A summary of the focus


group discussion will
be provided
A summary of the
results of the survey
will be included
The final report
recommends additional
approaches to
organizing and
financing HIV oral
health services in
Broward County