Economic evaluation of a community dental care model for people experiencing homelessness.

doi:10.21203/rs.3.rs-4172687/v1

Download PDF

Research

Economic evaluation of a community dental care model for people experiencing homelessness.

https://doi.org/10.21203/rs.3.rs-4172687/v1

This work is licensed under a CC BY 4.0 License

You are reading this latest preprint version

Aim

The study aims to conduct economic evaluation of the Peninsula Dental Social Enterprise (PDSE) programme for people experiencing homelessness over an 18-month period, when compared to a hypothetical base-case scenario (‘status quo’).

Methods

A decision tree model was generated in Treeage Pro Healthcare 2024. Benefit-cost analysis and cost-effectiveness analysis were performed using data informed by the literature and probabilistic sensitivity analysis (Monte-Carlo simulation with 1,000 cycles). The predetermined willingness to pay threshold was estimated to be £59,502 per disability-adjusted life year (DALY) averted. Costs (£) and benefits were valued in 2020 prices. Health benefits in DALYs included dental treatment for dental caries, periodontitis and severe tooth loss.

Results

The hypothetical cohort of 89 patients costs £11,502 (SD 488) and £57,118 (SD 2,784) for the base-scenario and the PDSE programme, respectively. The health outcomes generated 0.9 (SD 0.2) DALYs averted for the base-case scenario, and 5.4 (SD 0.9) DALYs averted for the PDSE programme. The DALYs averted generated £26,648 (SD 4,805) and £163,910 (SD 28,542) in benefits for the base-scenario and the PDSE programme, respectively. The calculated incremental benefit-cost ratio was 3.02 (SD 0.5) and incremental cost-effectiveness ratio was £10,472 (SD 2,073) per DALY averted. Uncertainty analysis demonstrated that the PDSE programme was 100% cost-effective.

Conclusions

Funding a targeted dental programme from the UK healthcare perspective that provides timely and affordable access to dental services for people experiencing homelessness is cost-effective.

Health sciences/Health care/Dentistry/Dental public health

Health sciences/Diseases/Dental diseases

Health sciences/Diseases/Oral diseases

The community-based targeted PDSE programme is a cost-effective model for delivering care to people experiencing homelessness.
Governments should consider the broader benefits and health impacts when providing dental services to vulnerable populations.
Policy-decision makers should look beyond cost-efficiency comparisons when formulating dental funding arrangements and related resource allocation decisions.

Oral health is an integral part of overall health, and plays an important role in the wellbeing of individuals and populations.¹ The majority of oral diseases can be prevented. Yet, they remain a global public health challenge affecting more than 3.5 billion people worldwide.² Socially excluded and vulnerable groups in society are disproportionately affected, with people in each lower socioeconomic position category, exhibiting successively worse oral health.³ The effects of oral diseases in terms of quality of life and economic impact are significant,⁴ contributing to 5–10% of health expenditure (>£3 billion/year).

Homeless populations experience the ‘cliff-edge’ of inequities as they experience very high levels of oral disease including dental caries, periodontal disease and tooth loss, as well as increased risk of oral cancer.^5–8 Additionally, there are often significant challenges in accessing dental services compared to the general population,⁹ commonly resulting in late presentation of oral diseases and the use of emergency department visits.¹⁰ It has been estimated that the health and social care needs of people experiencing severe and multiple disadvantage (which includes a combination of homelessness, problematic substance use and repeat offending) cost the United Kingdom (UK) public sector around £10 billion/year.¹¹

In the UK, access to National Health Service (NHS) dentistry has become increasingly challenging for all population groups. However, vulnerable people encounter additional barriers in accessing timely care.⁸ Both the lived experience of homelessness and features characteristics of dental services act as barriers to oral health.⁹ There are variations in the utilisation of dental services among the UK population,¹² which suggest that different models of care are required for different population groups.

Considering that many people experiencing homelessness find it challenging to access dental services, the Smile4life survey indicated a clear need for alternative models of care that supports people experiencing homelessness.¹³ This should include three ‘tiers’ of dental care: 1. Emergency dental services for those unable to access routine dental care; 2. Single-item treatments provided on an ad hoc occasional basis without the need to attend a full course of treatment; 3. Routine dental care/full course of treatment.¹³ Taking into account the “unfair and avoidable differences in health across the population and between different groups in society”,¹⁴ the NHS long term plan highlighted the important role that social enterprises can play in improving health outcomes.¹⁵ This due to their advantage in being able to respond more flexibility to patient needs than other NHS bodies.

Responding to local needs, Peninsula Dental Social Enterprise (PDSE), the clinical provider of the Dental School at the University of Plymouth in the Southwest of England, developed a community model of delivering dental care for people experiencing homelessness (details of the PDSE programme have been described elsewhere.¹⁶ The service provides routine and urgent care by a qualified dentist. An evaluation of the service highlighted significant patient benefits which often acted as a catalyst for change in multiple areas of a patient’s life.¹⁶

In fiscal terms, the analysis showed a significant gap between government funding levels and the actual cost of treating this population group,¹⁶ meaning that a service contract based on NHS England's current funding structure would not be economically viable. However, the degree to which the PDSE programme is cost-effective has not been investigated. In the UK, the National Institute for Health and Care Excellence (NICE) has guidelines that use economic evaluation to inform resource allocation decisions,¹⁷ and which consider both costs and health outcomes. An economic evaluation of the PDSE programme can provide important insight relevant to the future commissioning of services for groups experiencing social exclusion.

Aim

The aim of this study was to conduct economic evaluation of the PDSE programme for people experiencing homelessness when compared to a hypothetical scenario of ‘status quo’.

Economic evaluation was conducted to determine whether the PDSE programme¹⁶ is a cost-effective intervention from the UK healthcare perspective. The PDSE population cohort included 89 patients experiencing homelessness who accessed dental services within a period of approximately 18 months. This study was conducted using publicly available data in the literature and adhered to the principles of the Declaration of Helsinki.

Base-case scenario (‘status quo’)

A hypothetical cohort of patients experiencing homelessness was created as the base-case scenario. It assumed that only 17% of them had utilised dental services in the last 1–2 years.¹⁸ Timely access would have prevented disability. In addition, 27% of patients in this cohort would have at least one Accident and Emergency (A&E) admission due to dental problems¹⁸ likely due to worsened severity of dental caries. Given that there was an absence of A&E re-admissions, it was assumed that this rate was 3.244 over 18 months.¹⁹ For patients who did not utilise dental services, they had 1.32 higher odds for A&E admission.²⁰

Peninsula Dental Social Enterprise (intervention)

The intervention included all 89 patients experiencing homelessness who accessed dental services offered by PDSE. Treatments that were provided included 298 extractions, 224 restorations, 3 root canal treatments, 29 periodontal treatments, 38 partial dentures and 28 full dentures.¹⁶

Modelling approach

Benefit-cost analysis and cost-effectiveness analysis were conducted using the decision tree method using Treeage Pro Healthcare 2024 (TreeAge Software, LLC.) with probabilistic sensitivity analysis using Monte Carlo simulation with 1,000 cycles (Fig. 1). Where appropriate, cost parameters were generated using the gamma distribution with ± 10% of the expected value being assigned as the 95% confidence interval. The same rationale was applied to outcome parameters using normal distributions. A summary of the parameter variables is reported in Table 1.

Figure 1 The decision tree model developed for economic evaluation of the PDSE programme.

<Insert Fig. 1 here>.

Probability_Access_Dentistry = Proportion of people experiencing homelessness accessing dental services (last 1–2 years)

Probability_A_E_Homeless = Proportion of people experiencing homelessness having an admission and emergency visit.

NHS_Dentistry_Refusal_Odds = Increased odds of an admission and emergency visit if access to NHS dentistry was refused.

Table 1 Summary of the data source used to generate the decision tree model.

<Insert Table 1 here>.

Time horizon

The selected time horizon is 18 months.

Health benefit modelling

Estimating disability-adjusted life years

Health outcomes were quantified using methods adapted from the 2019 Global Burden of Disease Study²² to derive disability-adjusted life years (DALYs) averted. The health benefits included dental treatment for dental caries, periodontitis and severe tooth loss.

The disability weight of 0.010 (SD 0.004) for dental caries²² was applied to extractions, root canal treatment and restorations. Time spent with disability includes two components: 1) terminal pain and 2) periodic pain. Terminal pain was relevant to extraction and root canal treatment, which assumed constant pain for 55.2 days.²³ Periodic pain was applied for restorative procedures, which is a disability equivalent to one hour per day for the same duration of terminal pain.

For patients who received periodontal treatment, the disability weight of 0.007 (SD 0.003) for periodontitis²² was applied, with DALYs averted for 1 year.

Similarly, prosthetic dental services provided for partial and full dentures were associated with DALYs averted due to severe tooth loss. The disability weight of 0.067 (SD 0.013) for severe tooth loss²² was applied for the 18-month period.

For patients who had an A&E admission, it was assumed that DALYs accrued due to symptomatic utilisation of healthcare, primarily due to dental caries as the common cause of dental pain.^24,25

Costs

Costs are reported in the national currency (£) in 2020 prices.

For the intervention, each patient received dental services that had an average health expenditure of £854.50.¹⁶

The healthcare costs of an A&E admission is estimated to be £344, calculated from £418 in 2024²¹ deflated to 2020 prices.²⁶

Discount rate

Given the short time-horizon of 18 months, neither costs nor outcomes were discounted.

Economic evaluation

Economic evaluation is the comparative analysis of an alternative care pathway in terms of both costs and outcomes.²⁷

For the benefit-cost analysis, the incremental benefit-cost ratio (IBCR) was calculated to determine the marginal benefit in monetary terms relative to the costs of the intervention being compared. DALYs can be converted into monetary value based on previous costing methods.²⁸ One DALY is equal to £30,504 Gross Domestic Product per capita in 2020 constant prices.²⁹ If an intervention resulted in DALYs averted, it is considered a benefit, and vice versa; DALYs accrued is treated as a cost.³⁰ An IBCR greater than 1 indicates there is more benefit in monetary terms relative to the costs. The IBCR is calculated using the formula:

$$\frac{{Benefit}_{Intervention}-{Benefit}_{Base-Case Scenario} }{{Cost}_{Intervention}-{Cost}_{Base-Case Scenario} }$$

where the benefit includes DALYs averted converted into costs, and the costs include both the cost of the care pathway and the DALYs accrued converted into costs.

With the cost-effectiveness analysis, the calculated incremental cost-effectiveness ratio (ICER) was compared to a pre-determined Willingness-To-Pay (WTP) threshold. The WTP is a concept whereby a specified ‘threshold’ of monetary value is assigned to each unit of outcome gained to determine whether an intervention is cost-effective, usually decided by the decision-maker. In principle, if the additional cost generated by an additional unit of outcome is below the WTP threshold, the alternative care pathway should be adopted. Given that the NICE guideline does not have a WTP threshold per DALY averted, this was estimated as £59,502 per DALY averted with the UK considered a very high income country (US$69,499 in 2016 inflated to 2020 prices and converted to £.³¹ The ICER is calculated using the formula:

$$\frac{{Outcome}_{Intervention}-{Outcome}_{Base-Case Scenario} }{{Cost}_{Intervention}-{Cost}_{Base-Case Scenario} }$$

where the outcome is DALYs accrued, and the cost component includes the costs of the care pathways.

The economic evaluation modelled results are reported in Table 2.

Table 2 Results of economic evaluation outcomes using benefit-cost and cost-effectiveness analysis.

<Insert Table 2 here>.

The total estimated costs were £57,118 (SD 2,784) for the PDSE programme and £11,502 (SD 488) for the base-case scenario. The PDSE programme generated 5.4 (SD 0.9) DALYs compared to 0.9 (SD 0.2) DALYs averted for the base-case scenario. When DALYs were converted into monetary value, the benefits were £163,910 (SD 28,542) for the PDSE programme and £26,648 (SD 4,805) for the base-case scenario.

The IBCR was calculated to be 3.02 (SD 0.5), i.e., for every pound invested into the PDSE programme, the intervention produced an additional benefit of £2.02. The ICER was calculated to be £10,472 (SD 2,073) per DALY averted. The cost-effectiveness plane (Fig. 2) shows that the PDSE programme is 100% cost-effective and was robust to probabilistic sensitivity analysis.

Figure 2 The cost-effectiveness plane illustrating the modelled data points for the economic evaluation of the PDSE programme when compared to the base-case scenario.

<Insert Fig. 2 here>.

Each green dot indicates modelled outputs being cost-effective when comparted against the WTP threshold of £59,502 per DALY averted. The green circle indicates the 95% confidence interval of the 1,000 modelled data points.

Our study has shown that the PDSE programme for people experiencing homelessness is a cost-effective intervention with significant health benefits in terms of DALYs averted. Considering the high rate of visits to A&E for dental problems by people who experience homelessness, and associated cost implications, our findings have significant implications for the commissioning of dental services from the NHS. To our knowledge, this is the first study evaluating the cost-effectiveness of a dedicated model that provides urgent and routine dental care for people experiencing homelessness.

It is very common for people experiencing homelessness to suffer from the most severe complications of oral diseases such as pain and infections and for these to go untreated or to require emergency care.^2,5,10 A study in the USA¹⁰ has shown that odontogenic infections causing pain accounted for over 80% of emergency department visits for this population. Also, 46% of people experiencing homelessness who visited the emergency department for dental problems did so more than once during the study period.¹⁰ As the authors suggest,¹⁰ repeat emergency department visits indicate that dental problems impacted significantly on people experiencing homeless, and that they were unable to access appropriate dental care in the community. The treatment of non-traumatic dental problems at the emergency department is particularly interesting, since most of these problems can be resolved more effectively in a dental surgery.¹⁰ Insufficient access to dental care has been confirmed by both national and international studies, which indicate that this population has very limited access to routine and preventative healthcare.^32,33

The Marmot Review highlighted how the most advantaged groups often stand to get the greatest benefit from population-wide interventions.³⁴ Therefore, without attention to distributional impact, such interventions may actually increase inequities.³⁴ If the steepness of the social gradient in health is to be decreased, it is essential that we act universally, but at a scale and intensity proportional to the level of disadvantage and of health needs.³⁴ The unequal distribution and burden of oral diseases among vulnerable groups, including people experiencing homelessness, necessitates the development of novel dental care pathways which allow dental professionals to respond flexibly to the complex needs of this group.

In contrast to traditional models of NHS dentistry, where some patients may be required to pay for a proportion of treatment costs, the PDSE community clinic is free of charge to patients and provides flexibility around attendance. Despite an earlier evaluation demonstrating that the average cost per treatment course compares unfavourably with NHS contract funding if the service were solely state funded,¹⁶ the current study identified an additional £2.02 in cost benefits for every pound invested in the PDSE programme. This can be explained by the health benefits gained in monetary value, and the ability to access timely routine and urgent care through a supportive community model.

Besides the oral health improvements of people receiving dental care through the PDSE programme, there can be additional productivity and financial benefits to the NHS funding pool because of freed-up capacity in other parts of the NHS system. The transfer of dental commissioning responsibilities of dental services to Integrated Care Boards may present new opportunities for innovative commissioning of place-based models that tailor care to the needs of targeted populations. Further investigation of such data could be undertaken in studies.

There are currently different service models that provide dental care to people experiencing homelessness in England. Examples of best practice targeted services include “primary care delivery (‘high street’ dental practices), mobile dental units (MDUs), and community clinics operated through social enterprises”.³⁵ Since people experiencing homelessness have diverse needs, these models can complement each other to ensure that patients have access to dental care that is tailored to their circumstances.³⁵ Although a cost analysis of high street practices and MDUs is yet to be conducted, MDUs have shown to increase costs, with Units of Dental Activity (UDAs) at MDUs costing 2.4 times more than UDAs at fixed sites.³⁶ For some people experiencing homelessness, an MDU might be more effective, so a more costly model such as this may be justified according to local conditions.³⁷ Further research is warranted into the cost effectiveness of different targeted models when compared to mainstream ones.

Healthcare provision must be rationally targeted to those at greatest risk, in the greatest need, and experiencing the greatest difficulty accessing treatment, with care tailored effectively to their individual situations.³⁶ Considering high levels of co-morbidity among people experiencing homelessness and their complex social care needs, integrating health and social care appears to be an effective way of organising care around the individual. Some suggested ways to achieve this include co-location with other health or food provision facilities, or in open-access day centres with housing and social services, establishing links with support organisations and offering cross-referral opportunities between services.³⁷

The integration of health and social care can improve overall wellbeing outcomes for people experiencing homelessness, as well as contributing to ending homelessness,³⁸ with potential economic and societal benefits. The need for a combination of downstream, midstream and upstream interventions to promote oral health equity across the population³⁹ should not be underestimated. Additionally, to tackle oral diseases, it is necessary to have across the healthcare system, a focus on prevention that considers service delivery models that are tailored to and meet the needs of the target population.

Strengths and Limitations

A main strength of this study is that it expands on the application of economic evaluation techniques less commonly used in oral health context such as periodontitis⁴⁰ and severe tooth loss. Furthermore, modelled economic evaluations in oral health have often used a tooth-level model rather than the person-level model approach used in this study. Our work also synthesised and applied a methodology that combined the cumulative health outcomes in DALYs across three common oral diseases as a more realistic care pathway instead of an intervention targeting one oral disease at a time as mutually exclusive health states.

It is common that studies conducting the economic evaluation of oral health interventions use outcome measures that make it impossible to determine whether an intervention is cost-effective due to the absence of WTP thresholds⁴⁰ other than those established for DALYs and quality-adjusted life years (QALYs). The NICE guidelines generally adopt an explicit threshold of £20,000-£30,000 per QALY gained.¹⁷ Furthermore, our study provides a fairly conservative estimate of the DALYs averted generated from the PDSE programme given that many people experiencing homelessness do not have regular access to affordable dental care, and 13% had not seen a dental practitioner for more than 10 years.¹⁸

A key limitation of this study is the biased assignment of a hypothetical cohort of patients for the base-case scenario as the comparator to the PDSE programme. Ideally, matched data on A&E admissions, dental service utilisation and health outcomes at an individual level should be used for economic evaluation for both cohorts of people experiencing homelessness. However, it would be ethically problematic to deny dental care to patients if they are assigned to the base-case scenario under a more robust study design like a randomised controlled trial, given the high needs of people experiencing homelessness.^16,18

There are some limitations to the analysis which relate to the specific service model delivered by the PDSE programme and its costs, which includes provision for additional administration and outreach activities not associated with the delivery of dental services to people experiencing homelessness in other NHS settings. However, despite these additional costs, the PDSE programme was still found to be cost effective. Previous research has shown that community-based targeted dental programmes can potentially reduce homelessness and improve employability,⁴¹ and increasing dental care access can reduce dental-related emergency department visits.⁴² Whether the PDSE programme has led to a reduction in unscheduled dental care appointments or attendances at A&E is currently unknown.

Dental care provision for people experiencing homelessness necessitates using various service models that take their unique circumstances into consideration. Our study has shown that despite the higher cost compared to the standard NHS contract funding model, a community-based targeted service is a cost-effective model for delivering timely and affordable care to people experiencing homelessness. NHS dental commissioning approaches must shift from focusing on costs based on UDAs to one that focuses on need and reducing inequities in access to dental care.

Peres MA, Macpherson LMD, Weyant RJ, Daly B, Venturelli R, Mathur MR, et al. Oral diseases: a global public health challenge. Lancet Lond Engl. 2019;394(10194):249–60.
Watt RG, Daly B, Allison P, Macpherson LMD, Venturelli R, Listl S, et al. Ending the neglect of global oral health: time for radical action. Lancet Lond Engl. 2019;394(10194):261–72.
Sabbah W, Tsakos G, Chandola T, Sheiham A, Watt RG. Social Gradients in Oral and General Health. J Dent Res. 2007;86(10):992–6.
Jevdjevic M, Trescher AL, Rovers M, Listl S. The caries-related cost and effects of a tax on sugar-sweetened beverages. Public Health. 2019;169:125–32.
McGowan LJ, Joyes EC, Adams EA, Coyte A, Gavin R, Richmond C, et al. Investigating the Effectiveness and Acceptability of Oral Health and Related Health Behaviour Interventions in Adults with Severe and Multiple Disadvantage: Protocol for a Mixed-Methods Systematic Review. Int J Environ Res Public Health. 2021;18(21):11554.
Public Health England. Inequalities in oral health in England [Internet]. 2021 [cited 2024 Mar 22]. Available from: https://assets.publishing.service.gov.uk/media/6051f994d3bf7f0453f7b9a9/Inequalities_in_oral_health_in_England.pdf
Stennett M, Tsakos G. The impact of the COVID-19 pandemic on oral health inequalities and access to oral healthcare in England. Br Dent J. 2022;232(2):109–14.
Watt RG, Venturelli R, Daly B. Understanding and tackling oral health inequalities in vulnerable adult populations: from the margins to the mainstream. Br Dent J. 2019;227(1):49–54.
Paisi M, Kay E, Plessas A, Burns L, Quinn C, Brennan N, et al. Barriers and enablers to accessing dental services for people experiencing homelessness: A systematic review. Community Dent Oral Epidemiol. 2019;47(2):103–11.
Figueiredo R, Dempster L, Quiñonez C, Hwang SW. Emergency Department Use for Dental Problems among Homeless Individuals: A Population-Based Cohort Study. J Health Care Poor Underserved. 2016;27(2):860–8.
Bramley G, Fitzpatrick S, Edwards J, Ford D, Johnsen S, Sosenko F, et al. Hard Edges: Mapping Severe and Multiple Disadvantage in England [Internet]. 2021 [cited 2024 Mar 22]. Available from: http://www.lankellychase.org.uk/assets/0000/2858/Hard_Edges_Mapping_SMD_FINAL_VERSION_Web.pdf
O´Connor R, Landes D, Harris R. Trends and inequalities in realised access to NHS primary care dental services in England before, during and throughout recovery from the COVID-19 pandemic. Br Dent J. 2023 [cited 2024 Mar 11]; Available from: https://www.nature.com/articles/s41415-023-6032-1
Coles E, Edwards M, Elliott GM, Freeman R, Heffernan A, Moore A. Smile4life: The oral health of homeless people across Scotland [Internet]. Dundee: University of Dundee, Dental Health Services Research Unit; 2009. Available from: https://discovery.dundee.ac.uk/files/3399534/smile4life_report.pdf
NHS England. What are healthcare inequalities? [Internet]. 2024 [cited 2024 Mar 22]. Available from: https://www.england.nhs.uk/about/equality/equality-hub/national-healthcare-inequalities-improvement-programme/what-are-healthcare-inequalities/
NHS. NHS Long Term Plan [Internet]. 2019 [cited 2024 Mar 22]. Available from: https://www.longtermplan.nhs.uk/wp-content/uploads/2019/08/nhs-long-term-plan-version-1.2.pdf
Paisi M, Baines R, Worle C, Withers L, Witton R. Evaluation of a community dental clinic providing care to people experiencing homelessness: A mixed methods approach. Health Expect. 2020;23(5):1289–99.
Sculpher M, Palmer S. After 20 Years of Using Economic Evaluation, Should NICE be Considered a Methods Innovator? PharmacoEconomics. 2020;38(3):247–57.
Groundswell. Healthy Mouths: A peer-led health audit on the oral health of people experiencing homelessness [Internet]. Trust for London. 2017 [cited 2024 Feb 18]. Available from: https://tfl.ams3.cdn.digitaloceanspaces.com/media/documents/Groundswell-Healthy-Mouths-Report-Final-Web-2_sic5EBa.pdf
Lewer D, Menezes D, Cornes M, Blackburn RM, Byng R, Clark M, et al. Hospital readmission among people experiencing homelessness in England: a cohort study of 2772 matched homeless and housed inpatients. J Epidemiol Community Health. 2021;75(7):681–8.
Elwell-Sutton T, Fok J, Albanese F, Mathie H, Holland R. Factors associated with access to care and healthcare utilization in the homeless population of England. J Public Health. 2017;39(1):26–33.
The Kings Fund. NHS: Key Facts And Figures | The King’s Fund [Internet]. 2023 [cited 2024 Feb 18]. Available from: https://www.kingsfund.org.uk/insight-and-analysis/data-and-charts/key-facts-figures-nhs
GBD 2019 Diseases and Injuries Collaborators. Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet Lond Engl. 2020;396(10258):1204–22.
Whyman RA, Treasure ET, Ayers KM. Dental disease levels and reasons for emergency clinic attendance in patients seeking relief of pain in Auckland. N Z Dent J. 1996;92(410):114–7.
Boeira GF, Correa MB, Peres KG, Peres MA, Santos IS, Matijasevich A, et al. Caries Is the Main Cause for Dental Pain in Childhood: Findings from a Birth Cohort. Caries Res. 2012;46(5):488–95.
Pentapati KC, Yeturu SK, Siddiq H. Global and regional estimates of dental pain among children and adolescents—systematic review and meta-analysis. Eur Arch Paediatr Dent. 2021;22(1):1–12.
Bank of England. Inflation calculator [Internet]. 2024 [cited 2024 Feb 18]. Available from: https://www.bankofengland.co.uk/monetary-policy/inflation/inflation-calculator
Drummond M, Sculpher MJ, Claxton K, Stoddart GL, Torrance GW. Methods for the economic evaluation of health care programmes. Fourth edition. Oxford, United Kingdom; New York, NY, USA: Oxford University Press; 2015.
Righolt AJ, Jevdjevic M, Marcenes W, Listl S. Global-, Regional-, and Country-Level Economic Impacts of Dental Diseases in 2015. J Dent Res. 2018;97(5):501–7.
International Monetary Fund. World Economic Outlook Database, April 2022 [Internet]. IMF. 2023 [cited 2023 Nov 30]. Available from: https://www.imf.org/en/Publications/WEO/weo-database/2022/April
Woldemariam W. Prioritization of Low-Volume Road Projects Considering Project Cost and Network Accessibility: An Incremental Benefit–Cost Analysis Framework. Sustainability. 2021;13(23):13434.
US Inflation Calculator. Find US Dollar’s Value From 1913–2023 [Internet]. 2023 [cited 2023 Dec 19]. Available from: https://www.usinflationcalculator.com/
Daly B, Tim Newton J, Batchelor P. Patterns of dental service use among homeless people using a targeted service. J Public Health Dent. 2010;70(1):45–51.
Freitas DJ, Kaplan LM, Tieu L, Ponath C, Guzman D, Kushel M. Oral health and access to dental care among older homeless adults: results from the HOPE HOME study. J Public Health Dent. 2019;79(1):3–9.
Marmot M. Fair Society, Healthy Lives: The Marmot Review [Internet]. 2010 [cited 2022 Jul 4]. Available from:
Serban S, Bradley N, Atkins B, Whiston S, Witton R. Best practice models for dental care delivery for people experiencing homelessness. Br Dent J. 2023;235(12):933–7.
Simons D, Pearson N, Movasaghi Z. Developing dental services for homeless people in East London. Br Dent J. 2012;213(7):E11–E11.
Bradley N, Heidari E, Andreasson S, Newton T. Models of dental care for people experiencing homelessness in the UK: a scoping review of the literature. Br Dent J. 2023;234(11):816–24.
National Institute for Health and Care Excellence. Integrated health and social care for people experiencing homelessness [Internet]. NICE; 2022 [cited 2024 Mar 22]. Available from: https://www.nice.org.uk/guidance/ng214/resources/integrated-health-and-social-care-for-people-experiencing-homelessness-pdf-66143775200965
Dawson ER, Stennett M, Daly B, Macpherson LMD, Cannon P, Watt RG. Upstream interventions to promote oral health and reduce socioeconomic oral health inequalities: a scoping review protocol. BMJ Open. 2022;12(6):e059441.
Nguyen TM, Tonmukayakul U, Le LKD, Calache H, Mihalopoulos C. Economic Evaluations of Preventive Interventions for Dental Caries and Periodontitis: A Systematic Review. Appl Health Econ Health Policy. 2023;21(1):53–70.
Ghoneim A, Ebnahmady A, D’Souza V, Parbhakar KK, He H, Gerbig M, et al. The impact of dental care programs on healthcare system and societal outcomes: a scoping review. BMC Health Serv Res. 2022;22(1):1574.
Cothron A, Diep VK, Shah S, Brow A, Thakkar-Samtani M, Okunseri C, et al. A systematic review of dental‐related emergency department visits among Medicaid beneficiaries. J Public Health Dent. 2021;81(4):280–9.

There is no duality of interest

Download PDF

Review #3 received at journal
23 May, 2024
Reviewer #3 agreed at journal
22 Apr, 2024
Reviewer #2 agreed at journal
18 Apr, 2024
Reviewer #1 agreed at journal
14 Apr, 2024
Reviewers invited by journal
12 Apr, 2024
Editor assigned by journal
28 Mar, 2024
Submission checks completed at journal
28 Mar, 2024
First submitted to journal
26 Mar, 2024

You are reading this latest preprint version

Economic evaluation of a community dental care model for people experiencing homelessness.

Status:

Version 1

Abstract

Figures

Key points

Introduction

Aim

Methodology

Base-case scenario (‘status quo’)

Peninsula Dental Social Enterprise (intervention)

Modelling approach

Time horizon

Health benefit modelling

Estimating disability-adjusted life years

Costs

Discount rate

Economic evaluation

Results

Discussion

Strengths and Limitations

Conclusions

References

Additional Declarations

Status:

Version 1