Ryan White CARE Act Title I Dental Impact Evaluation and Cost Effectiveness

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

2
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

3
No Broward County patients or dental providers
images were used in this presentation
4
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

5
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

6
What are the benefits of oral health treatment
for HIV patients?
7
Importance of HIV Oral Health Care

• Oral conditions are important markers in the
  clinical spectrum of HIV infection

• 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

8
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

9
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

10
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

11
What is the HIV oral health funding experience of
other CARE Act grantees?
12
Broward EMA ranks 11th among Title I EMAs in
planned FY 2004 total direct service funds
allocated to dental services
EMA Total FY 2004Dental Total FY 2004 Direct Service to Dental MAI FY 2004Dental 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
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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
  cost-effectiveness, the methods used to pay for
  dental services, and how services were organized
• Similarly, Dental Reimbursement Programs (DRPs)
  were contacted by email
• Published articles and reports were searched
• HAB dental expert also queried

14
Learning From Other CARE Act Grantees

• No grantees contacted reported conducting
  cost-effectiveness 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

15
What is the utilization experience of Title
I-funded HIV oral health services and related
expenditures?
16
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
• Childrens Diagnostic and Treatment Center Dental
  Clinic, S Federal Hwy, Ft Lauderdale
• South Regional Health Center Dental Clinic,
  Pembroke Rd, Hollywood

17
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 co-located with
  medical clinics
• NOVA is adding a new site co-located at Center
  One
• Dental clinics do not have evening appointments

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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 (median3 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

19
What are the expenditures associated with Title
I-funded regular and specialty dental services?
TYPE OF SERVICE TYPE OF SERVICE
YEAR REGULAR SPECIALTY
2002 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 (median408), with expenditures
  ranging from 128 to 4,237
• An average of 791 was spent per patient
  (median800) for specialty dental services, with
  expenditures ranging from 42 to 8,050

20
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
21
What are HIV Broward County residents
perceptions of barriers to access and retention
in HIV general and specialty oral health care?
22
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

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Focus Group Questions

• 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?

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Survey Design

• A convenience sample of HIV Broward County
  residents is being used due to absence of
  systematic gathered data to identifying survey
  subjects

• 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 surveys 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

25
What is the quality of dental services provided
by Broward County Title I-funded dental clinics?
26
Chart Review Process

• 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 projects dental consultant
• Study period March 2004 February 2005

• 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 clinics random
  sample list

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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

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Chart Review Items

• Intake form complete?
• Name, SSN, address, birth date, gender,
  race/ethnicity
• Primary care MDs name and contact information
  complete?
• HIV status, income, and Broward County residency
  documented?
• Emergency contact identified?
• Signed consent for treatment?
• Patients 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?

• Is patients 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?

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Chart Review Items

• Preventive fluoride program, if appropriate?
• Is patients 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?

30
Chart Review Findings Considerations for Dental
Record Staff

• Most dental charts recorded patient identifying
  information
• All dental charts recorded patient name, Social
  Security number, address, telephone number, and
  birth date
• Primary care MDs 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

31
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

32
Chart Review Findings Considerations for Dental
Personnel

• 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

33
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 patients 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

34
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

35
How do the chart review findings compared to
Title I standards?
Category Outcome Indicator Chart Review Finding
Morbidity Patients receive preventive care 90 of patients are assessed for opportunistic infections 98.9
Morbidity Patients receive preventive care 90 of patients receive soft tissue exam, including perioral tissue and oral mucosa 98.9
Morbidity Patients receive preventive care 90 of patients receive exam of the gingival and periodontal structures 96.7
Morbidity Patients receive preventive care 90 of patients receive preventive education on oral techniques and self care 91.1
Treatment adherence Patients complete treatment 90 of patients with more than one visit will have a dental treatment plan recorded in the dental record 95.7
Treatment adherence Patients complete treatment 70 of patients examined will have completed their initial treatment plan within six months 77.2
36
How do the chart review findings compared to
Title I standards?
Category Indicator Chart Review Finding
Provider completes a medical/dental history form in initial visit 100 of patient charts show complete medical/dental history 95.7 (medical)
Treatment plan is developed based on the initial comprehensive exam 100 of patients chart have a treatment plan 100
Patient treatment plan is reviewed and updated as necessary by the dental provider 100 of patients charts show review, as needed 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
37
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 patients 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

38
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

39
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 patients 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

40
Are dental services purchased with Broward County
Title I funds cost-effective?
41
What are HABs expectations regarding
cost-effectiveness?

• 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
42
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 longer-term based on how soon
  they occur after program participation begins

Ryan White CARE Act Title I Manual
43
Using HABs 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
Agree on the standards of care or benchmarks related to service outcomes Standards of care defined by Oral Health Service Delivery Model
Determine the unit or per-client costs of these services The cost of a dental visit is set as 128 per general dental visit
Determine the outcomes of the service Short-term outcomes associated directly with Broward Title-I funded dental services have been achieved.
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) It costs 128 in Title I oral health funds to ensure that a patient receives preventive oral health care and completes treatment
Ryan White CARE Act Title I Manual
44
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 "cost-effective"

45
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
  judgmentwhat you think is a good price for an
  additional outcome, someone else may not

46
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

47
Are dental services purchased with Broward County
Title I funds cost-beneficial?
48
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

49
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

50
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

51
What are the outcomes associated with dental
services purchased with Broward County Title I
funds?
52
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

53
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?

54
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?

55
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