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HERRERA ET AL .
(Continued) Additional question raised by the WG
treatment) and highlights the uncertainty in the values used in the analysis. An incremental cost-effectiveness ratio (ICER) was created by considering the increase in cost of a particular programme (i.e., specialist or general dentist in either setting) by the increase in benefit (outcome). The results of the analysis showed that SPC when provided in specialist practice was more effective than that delivered by a general practitioner, in terms of tooth loss and clinical attach- ment. SPC in specialist practice, however, costs € 4466 more than a general dentist in private practice, and € 5938 more than a general dentist in a state health service system. The ICER for SPC delivered in specialist care (general dentist in private practice as baseline) was € 217 for one extra tooth year or an extra € 1130 for 1 mm less attachment loss. When using the general dentist in a state-supported health service as a baseline, specialist care equated to € 288 for one extra tooth year or an extra € 1503 per 1 mm loss of attachment. Undoubtedly, compliance with recall appointments and efficiency and appropriateness of care is crucial to our understanding of cost- effectiveness. No data on compliance were given for the cohort of patients who received SPC in general practice.
R11.7: Expert consensus-based statement We do not know if long-term SPC is cost-effective when considering direct and indirect costs . Supporting literature (Gaunt et al., 2008) and Expert opinion Quality of evidence Not applicable Grade of recommendation GradeO — $ Statement: unclear, additional research needed Strength of consensus Unanimous consensus (0% of the group abstained due to potential CoI)
Background
Intervention
Costs incurred by SPC are complex and include both direct and indirect costs. Direct costs include elements such as the recall visits themselves and/or costs of re-treatment, while the consequences of periodontitis (e.g., cost of oral rehabilitation following tooth extraction or root caries) and time commitments from the patient (i.e., absenteeism from work) are considered indirect costs. There are also “ intangible ” costs such as impact on quality of life and number of healthy life years.
Consistency, balance of benefit and harm Not applicable.
Overall certainty of the evidence Very low.
From evidence to recommendation — additional considerations
Available evidence
Number and design of included studies No studies reported on direct, indirect and intangible costs in SPC.
Acceptability It is unknown whether patients prefer SPC appointments in the specialist environment or in general practice. Often, a shared responsibility exists (between specialist and general dental prac- tices), which may reduce overall costs, possibly at the expense of tooth or CAL.
Risk of bias Not applicable.
Effect sizes and their clinical relevance One systematic review (Gaunt et al., 2008) concluded that SPC deliv- ered in a specialist environment led to greater periodontal stability (clinical attachment) and higher tooth survival rates when compared with general practice, but was more expensive to deliver (direct costs) in the specialist environment. The systematic review con- ducted an analysis on cost-effectiveness based on data from one study (Axelsson & Lindhe, 1981) being extrapolated over a 30-year period. The analysis was from the perspective of a single patient with the primary patient-based outcome of tooth loss and secondary outcome of CAL. The authors calculated “ tooth years lost ” , which considered time as a factor. Thus, one tooth lost after the first year of SPC, equated to 30 tooth years lost over the course of the evalua- tion. The comparison was taken for those patients who received SPC in specialist care (charges based on one specialist practice in North East England) versus in a general dental practice (charges based on state health service charges in Scotland). Importantly, this model assumed that only SPC would be undertaken (no periodontal re-
Feasibility Not applicable.
Ethical considerations Limited evidence exists that regular SPC is beneficial to the patient (reducing tooth loss and disease progression/recurrence). Although SPC delivered in specialist practice appears to increase tooth survival and reduce CAL when compared with general practice, this comes at a higher cost, which may be a barrier for some patients. Economic considerations Limited evidence of the cost-effectiveness of SPC regarding direct and indirect costs exists and should be a clear future research priority.
Legal considerations Not applicable.
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