Tuti Ningseh Mohd Dom (PhD)

Presented at the International Conference on Periodontal Health 1-2 August 2015 Periodontal Disease: Overcoming Challenges and Moving Forward

What is economic burden?

The economic cost to the nation associated with expenditures on a disease preventive, screening

and treatment services,

the economic cost associated with time and effort spent by patients and their families undergoing

treatment and the economic cost associated with lost productivity due to disease-related disability

and premature death.

The cost-of-illness (COI) study

One approach to estimating this burden is the Cost-of-Illness study, that uses various national level data sources to obtain estimates of these various components

It is very rare to find cost studies of oral care employing the COI approach

Why study economic burden of a disease? http://www.who.int/choice/economicburden/en/

Statistics on morbidity and mortality of disease help estimate the burden of disease in populations, however they provide an incomplete picture of the adverse impact of ill health on human welfare.

In particular, the economic consequences of poor health can be substantial. E.g. impact of ill-health on a household’s income or a firm’s profits, or the aggregate impact of a disease on a country’s current and future gross domestic product (GDP).

Uses of economic burden studies

Useful for planning health budgets Comparisons of strategies

Basis for priority setting

Projection of future cost of programmes

Convince administrators and policy-makers of the magnitude of burden associated with a particular disease

For example, diabetes and cardiovascular diseases exert considerable economic impacts on health care systems, societies and the individual patients through the need for continued care and loss of productivity - prevention is “cheaper” than cure

Treatment of oral diseases account for the fourth most expensive disease in many industrialised countries, and costs are often borne by patients’ out-of-pocket payments [Petersen et al 2005].

While cost-related studies in oral healthcare are fewer compared to medical care, cost-of-illness (COI) studies of oral diseases are extremely rare [Fardal et al 2012, Ide et al 2009]

Periodontitis is an established and widespread chronic disease, yet its burden on healthcare costs remain largely neglected.

Most studies estimating costs of periodontal care focus on cost of specific periodontal treatment modalities but not the cost of managing the whole spectrum of the disease itself [Braegger 2005, Gjermo & Grytten 2009, Heasman et al 2011]

The neglected burden of periodontal diseases

Periodontal diseases, like any other oral conditions, on their own do not cause death.

However, its known links with known non-communicable diseases such as diabetes and cardiovascular diseases (Chapple et al 2013, Schenkein & Loos 2013) increases its role in contributing to the disease burden of these systemic conditions which may bring about fatality.

A recent review of periodontitis patients dental records in Malaysia indicated that at least a quarter of these patients suffer from diabetes mellitus and hypertension (Tuti et al 2014).

Jeffcoat, M., et. al., Periodontal Therapy Improves Outcomes in Systemic Conditions, 2014

A considerable amount of medical resources is being used for managing DM, PD and their several complications that can occur. A healthy mouth could mean thousands in healthcare savings!

The Increasing Global Burden of Periodontitis [Marcenes et al 2013]

• Oral diseases affect 3.9 billion people worldwide

• 291 diseases and injuries: Severe periodontitis (CPI=4, CAL 6 mm or a gingival pocket depth of >5 mm) is ranked 6th (11%) – higher than cardiovascular diseases.

• In the same study, severe periodontitis has been cited to have a mean disability-adjusted life years (DALYs) which was ranked at number 77. Disability was defined as “bad breath, a bad taste in the mouth, and gums that bleed a little from time to time”

In 2010, about 94.0% of Malaysian adults have periodontal disease

30.3% have shallow pockets (CPI=3)

18.2% have deep pockets (CPI=4)

• This is translated into a total of 48.5% of the adult population with periodontitis, or an estimated quantum of 11.5 million adults!

Study rationale

An estimate of economic burden of managing periodontitis will assist in allocation of resources and provide an economic framework for evaluation of related healthcare programmes

Aim of study

• To estimate the economic burden associated with the specialist management of periodontitis in Malaysia from the societal perspective.

Economic burden

Periodontal therapy

Host immune response

Periodontitis

Lifestyle: Stress, smoking

Co-morbidity: Hypertension, diabetes

Genetics

Dental plaque

Microorganism

Clinical burden

RIS

K F

AC

TO

RS

E

TIO

LOG

Y

One-year specialist periodontal programme

Cost per patient

The economic burden of

periodontitis is estimated

by combining the

frequency (prevalence)

of disease with the cost

of treatment

CONCEPTUAL FRAMEWORK 8/7/2015 13

Prevalence

Methods (1) Determination of Economic Burden

Clin

ical

Bu

rde

n

Co

st A

nal

ysis

Review of periodontal disease data

from National Oral Health Survey of

Adults 2010

Review of National Census Data 2010

to estimate proportion and number

of adults at risk for periodontitis

Costing from the providers’

perspective

Costing from the patients’

perspective

ECONOMIC

BURDEN

Tuti et al 2014. Cost analysis of Periodontitis management in public sector specialist dental clinics BMC Oral Health 14:56

Methods (2) : Patient recruitment and one-year periodontal therapy at specialist clinics

Methods (3): Cost analysis

Conducted from the societal perspective: the economic viewpoint of the provider, Ministry of Health, Malaysia, and the patients

Employed two costing methods: the step-down and activity-based costing (ABC) methods, which were substantiated by a clinical pathway.

The scope of costs included resources consumed for 30 procedures classified into diagnostics, non-surgical periodontal therapy and surgical interventions performed for periodontitis patients

Methods (4): Cost components

Cost

Direct cost Indirect cost

Dental procedures

including diagnostic

tests (equipment,

supplies, time taken,

staff salary)

Non-medical/ Dental Medical/ Dental Productivity loss

Programme

administration, physical

space, utilities (water,

electricity, telephone),

patients’ out-of-pocket

expenses (meals,

travels, etc)

Time spent by patient

seeking care (work

days/ hours lost)

Total cost per procedure = dental equipment cost + dental consumables cost+ staff salary + administrative cost (building, traveling, staff training, utilities, professional services, printing, hospitality, cleaning and sterilisation services)

Methods (5): Sources of cost data

Provider cost: clinic, annual returns, administrative and financial record for year 2011, as well as observation of 60 patients undergoing various treatments.

Patient cost: diaries provided primary data for patient out-of-pocket expenditures and time taken off work, whenever applicable, for a period of twelve months after being recruited into the study

Tuti et al 2014. Cost analysis of Periodontitis management in public sector specialist dental clinics BMC Oral Health 14:56

Average cost (S.D) in RM

Provider cost

Patient cost Total cost

Per patient/ year

2,524 (1,420)

296

(237)

2,820

(1,550) Per outpatient visit

337 (99) 39 (24) 376 (101)

8/7/2015 20

Provider cost per outpatient visit = Capital cost + Recurrent cost Capital cost = Building cost + Equipment cost (≥RM 500) Recurrent cost = Utility cost + maintenance cost + staff emolument and benefits + stocks and dental consumables/ supplies cost + drug cost

Patient cost per outpatient visit = Transportation cost + meals and beverages cost + clinic fees + productivity loss + others (crèche etc.).

Results (1): Cost was substantial, higher burden on provider

Disease

severity

Cost (RM)

Mean S.D

Mild 1,757 978

Moderate 2,545 1,499

Severe 3,174 1,277

8/7/2015 21

Level of significance α = 0.05, ANOVA, P=0.022 (Post-hoc Bonferroni test, P=0.043 for differences between mild and

severe periodontitis)

Results (2): The more severe, the higher the cost!

Mix of treatment Cost (RM)

Mean S.D

I 1,962 1,142

II 3,102 1,321

II 4,847 1,323

IV 5,103 1,154

8/7/2015 22

I – nonsurgical only (NSPT), II – NSPT, nonsurgical rehabilitative therapy (NSRT), III – NSPT, PS and NSRT, IV – NSPT and periodontal surgery (PS) Level of significance α = 0.05, ANOVA, P<0.001 (Post-hoc Bonferroni test, P<0.001 for all pairwise comparisons except for differences between groups III and IV whereby P=1.00)

Results (3) : It cost higher to treat patients who required surgical compared to those requiring

non-surgical treatment alone

8/7/2015 23

Results (4): Almost half of the adult population totalling 11.5 million people suffer from either

moderate or severe periodontitis.

Moderate periodontitis

Severe periodontitis

All cases

% of population with periodontitis (Oral Health Division, MOH, 2012)

30.30% 18.2% 48.5%

Number of adults at risk of periodontitis (aged 15 and above) (National census report, 2011)

- - 23,757,994

Number of adults estimated as having periodontitis

7,198,672 4,323,955 11,522,627

8/7/2015 24

Results (5): To manage all cases of periodontitis at the national level will cost the country approximately RM

32.5 billion, 3.83% of the GDP!

*Malaysia's GDP (Gross Domestic Product), 2011 = RM 847.3 billion

Moderate periodontitis

Severe periodontitis

All cases

% of population with periodontitis

30.30% 18.20% 48.5%

Economic burden RM 20.3 billion RM 12.2 billion RM 32.5 billion

% of GDP* 2.40% 1.44% 3.83%

Economic burden from providers' perspective

RM 18.2 billion

RM 10.9 billion

RM 29.1 billion

% of Ministry of Health budget

107.7% 64.7% 172.4%

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2

4

6

8

10

12

14

16

18

I II III IV

Fir

st-

ye

ar

tre

atm

en

t c

os

t fo

r p

roje

cte

d

nu

mb

er

of

pati

en

ts b

y t

rea

tme

nt

mix

(R

M)

Bil

lio

ns

Types of treatment mix

I – nonsurgical only (NSPT), II – NSPT, nonsurgical rehabilitative therapy (NSRT), III – NSPT, PS and NSRT, IV – NSPT and periodontal surgery (PS)

Study insights Periodontitis is a disease which seems unassuming in nature when it is at an early stage.

Because of this, most patients will not appreciate the need to seek early treatment.

Because of this, policymakers will not appreciate and address the potential impacts or threats of this disease.

Measuring the economic burden imposed by periodontitis on society as a whole means quantifying the consumption of health care resources and production losses incurred by the disease.

Conclusions

This study validates the longstanding hypothesis that a heavy economic burden is imposed on health care systems and the society to provide care for patients with periodontitis. It is comparable and even higher than economic burden of some chronic diseases in the country.

The more severe, the greater the need, the greater the economic burden!

Interpretation of findings is limited by the scope (specialist care, public sector) and duration of the study (first year of treatment)

Recommendations

Raise awareness among policy-makers and the public about the negative economic impact of periodontitis

Further emphasise the need for oral disease prevention and oral health promotion.

Focus on primary prevention and early detection of signs and symptoms reinforced and targeted to the younger age group.

Closing thoughts With such an economic burden higher than the health budget itself, and so many health needs of the population to cater for, no country will be able to meet these periodontal treatment needs

As it is, utilisation of public sector dental clinics including specialist periodontal clinics among adults is already very low.

It is clear that many patients have been or will be left under-treated or untreated and will potentially suffer the negative consequences

It is our collective responsibility to solve this problem

Thank you

8/7/2015 30

Ministry of Health Malaysia Ministry of Higher Education Faculty of Dentistry, UKM Faculty of Medicine, UKM UNU-IIGH

tutinin@gmail.com

Q&A One who does not count the cost, pays the price