Are Publicly Financed Dental Care Programs in Ontario Delivering the “Best Bang for their Buck?”...
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Transcript of Are Publicly Financed Dental Care Programs in Ontario Delivering the “Best Bang for their Buck?”...
1
Are Publicly Financed Dental Care Programs in Ontario
Delivering the “Best Bang for their Buck?”
E. Cardoso, V. Pilly, C. Quiñonez
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Outline
• Current situation
• Strategies abroad
• Conceptual framework
• Multi-Criteria Decision Analysis (MCDA) tool
• Strengths & Weaknesses
• Conclusion
3
Current situation
• Imbalance between financial resources
and challenges
– Increasing demand
–Higher costs
–Ethical dilemmas (Xie et al.,
2011)
• Sustainability of dental care programs
• Recent call to increase access
4
Current situation
• Challenge = Opportunity
– Chase the “best bang for their buck”
– Enhance process effectiveness & health outcomes
• Mantra of “no new dollars”
– Scrutinize the basket of dental care services
– Resource allocation optimization (Elshaug et al.,
2009)
– Evidence and best practices
5
Strategies abroad
Identify interventions with questionable
outcomes (Garner & Littlejohns , 2011)
Identify unsafe or ineffective
services
(Elshaug et al., 2012)
Ethical principles for resource allocation(WHO,2004)
6
Conceptual framework
• Decision support tool
– Multi-Criteria Decision Analysis (MCDA)
– Health Technology Assessment (HTA)
• Evaluate existing or future practices
• Evaluation phase or planning phase
• Help decision action toward program
objectives
Yes
No
Yes
No
No
Yes
No
Procedure
Program Objectives Analysis
Are program objectives
met?
Do not fund
Analysis against need
Is procedure needed?
Analysis against effectiveness
Is procedure effective?
Analysis against appropriateness
Is procedureappropriate?
Is it the only option?
Fund
Yes
Yes
Is it cost effective?
Cost-effective analysis
Yes No
Analysis deferred?
No
No
YesProfessionalor Patient
preference?
Procedure analysis
YesNo
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Building the proposed MCDA
• Various criteria listed and arranged in a
hierarchical, priority-setting manner
• Dental procedure must satisfy all listed
decision criteria to be funded
– Fails to meet criterion definition flagged not
to be funded
– Lacks evidence considered for evidence-
based review
Yes
No
Yes
No
No
Yes
No
Procedure
Program Objectives Analysis
Are program objectives met?
Analysis against need
Is procedure needed?
Analysis against effectiveness
Is procedure effective?
Analysis against appropriateness
Is procedureappropriate?
Yes
9
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Program Objective Analysis
• Procedure should:
– Reflect on the founding principles of
the program
– Support the ultimate goals or
programs objectives
– Preserve the sustainability of the
program
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Need Analysis
• Instrumental aspect of “need”
• Not linked to ill health
• “Minimum amount of resources required
to exhaust capacity to benefit” (Culyer and
Wagstaff, 1993)
• Some needs ought to go unmet to be
equitable (Culyer , 1998)
12
Effectiveness Analysis
• Achieved its outcome in real life setting (Guindo, 2012)
• Strength of evidence for evidenced-based
decision (Schanschieff , 1986)
• How much improvement after the
procedure is provided (Lavis, 1996)
• Basis for ‘Approppriateness’ (Lavis, 1996)
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Appropriateness Analysis
• Effective for a particular patient or
population
• No efforts are made to balance benefits
and costs yet (Lavis, 1996)
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Cost-effectiveness Analysis
• Identify worth financing services from other
options (Johnson et al., 2009)
• Simplest criterion
• Last in the hierarchy (Musgrove, 1999)
• Other options for public funding (Musgrove, 1999)
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Professional / patient preferences Analysis
• Further analysis to avoid resource
overutilization
• Individual welfare is not for the scope of
social responsibility (Wikler, 2002)
Yes
No
Yes
No
No
Yes
No
Procedure
Program Objectives Analysis
Are program objectives met?
Analysis against need
Is procedure needed?
Analysis against effectiveness
Is procedure effective?
Analysis against appropriateness
Is procedureappropriate?
Yes
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Yes
Do not fund
Fund
Yes
Cost effective ?
Cost-effective analysis
Yes No
Analysis deferred?
No
No
YesProfessional or Patient
preference?Procedure
analysis
Yes
No
Only option ?
17
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Strengths
• Systematic and evidence-informed tool
• Rational and transparent decision-making
process
• Identifies intrinsic values of each procedure
• Drives program performance according to
issues of sustainability
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Weaknesses
• Resistance from service providers
• Resistance from funders
• Centralized administration
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Conclusion
• Inequality in access to dental care as a public
health issue
• Sustainability of dental public health programs
• Maximize health benefits as an ethical objective of
the health care system
• Proposed systematic tool
– Evaluate current public oral health programs against
their strategic goals
– Push towards a stronger policy which includes
vulnerable populations other than children
22
References• Culyer AJ. The morality of efficiency in health care — some
uncomfortable implications. Health Econ 1992; 1: 7-18.
• Culyer, A. Need-is a consensus possible? J. Med. Ethics 24, 77-80
(1998)
• Elshaug, A., Moss, J.R., Littlejohns, P., Karnon, J., Merlin, T.L.&
Hiller, J.E. (2009) Identifying existing health care services that do
not provide value for money. MJA 190, 5: 269-73.
• Elshaug, A. G., Watt, A. M., Mundy, L. & Willis, C. D. Over 150
potentially low-value health care practices: an Australian study.
Med. J. Aust. 197, 556-560 (2012)
• Garner, S. & Littlejohns, P. Disinvestment from low value clinical
interventions: NICEly done? BMJ 343, d4519 (2011)
23
References• Guindo, L. A. et al. From efficacy to equity: Literature review of decision criteria for
resource allocation and healthcare decisionmaking. Cost. Eff. Resour. Alloc 10, 9-7547-
10-9 (2012)
• Johnson, A. P. et al. Health technology assessment: a comprehensive framework for
evidence-based recommendations in Ontario. Int. J. Technol. Assess. Health Care 25,
141-150 (2009)
• Lavis, J. N. & Anderson, G. M. Appropriateness in health care delivery: definitions,
measurement and policy implications. CMAJ 154, 321-328 (1996)
• Musgrove, P. Public spending on health care: how are different criteria related? Health
Policy 47, 207-223 (1999)
• Ontario Association of Public Health Dentistry (2005) Preparing for change, Retreat April 27 - 29,
2005. Barrie: Vision Management Services, Ontario Association of Public Health Dentistry.
• Quiñonez C, Sherret L, Grootendorst P, Shim MS, Azarpazhooh A, Locker D. An
environmental scan of provincial/territorial dental public health programs. Office of the
Chief Dental Officer, Health Canada. (2007) http://www.fptdwg.ca/English/e-
environmental.html
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References
• Schanschieff S. Report of the committee of enquiry into unnecessary
dental treatment, H M Stationery Office, Great Britain Department of
Health and Social Security, England, 1986
• Wikler, D. Personal and social responsibility for health. Ethics Int. Aff.
16, 47-55 (2002)
• World Health Organization (2004): Guidance on ethics and equitable
access to HIV treatment and care. http://www.who.int/ethics/Guidance
%20on%20Ethics% 20and%20HIV.pdf.
• Xie, F. et al. Using health technology assessment to support evidence-
based decision-making in Canada: an academic perspective. Expert
Rev. Pharmacoecon Outcomes Res. 11, 513-521 (2011).