A cost-minimization analysis of root canal treatment before and after education in nickel-titanium rotary technique in general practice.

AIM: To compare root canal treatments performed before and after education in a nickel-titanium rotary technique (NiTiR) with respect to costs for instrumentation and number of instrumentation sessions in a County Public Dental Service in Sweden. METHODOLOGY: Following education, 77% of the general dental practitioners adopted completely the NiTiR. The randomly selected sample comprised 850 root canal treatments: 425 performed after the education, mainly using the NiTiR-technique (group A) and 425 performed before, using mainly stainless steel hand instrumentation (SSI) (group B). The number of instrumentation sessions in root canal treatments in group A and B was calculated. A CMA was undertaken on the assumption that treatment outcome was identical in group A and B. Direct costs associated with SSI and NiTiR were estimated and compared. Investment costs required for implementation of NiTiR were calculated, but not included in the CMA. RESULTS: Instrumentation sessions were counted in 418 (98%) root canal treatments performed in group A and 419 (99%) in group B. The number of instrumentation sessions in group A was significantly lower; 2.38, compared with 2.82 in group B (P < 0.001). Thus, on average, for every second root canal treatment performed after the education, one instrumentation session was saved. Root canal treatments in teeth with one canal, and three or more canals, were completed in significantly fewer instrumentation sessions after the education (P < 0.001). Direct costs of instrumentation sessions were SEK 2587 (USD 411) for group A and SEK 2851 (USD 453) for group B, for teeth with one canal, and SEK 2946 (USD 468) for group A and SEK 3510 (USD 558) for group B, for teeth with three or more canals (year 2011). Root canal treatments of teeth with two canals showed no significant difference with respect to number of instrumentation sessions and costs. CONCLUSIONS: Significantly fewer instrumentation sessions were required in group A, and root canal instrumentation therefore costs less than in group B. On the assumption that treatment outcome is identical in group A and B, root canal instrumentation performed after the education was more cost-effective.

An evaluation of the QSP and the QPP: two methods for measuring patient satisfaction.

BACKGROUND: Patient satisfaction is a function of several variables addressing reasons why it is important to use methods in which these different factors can be isolated and their importance analysed. OBJECTIVE: In this project, two methods using this approach were used: the 'Quality from the Patient's Perspective' and the 'Quality, Satisfaction, Performance' models. The aim of the present study is to evaluate these two different methods with respect to application, strengths and weaknesses. DESIGN: In the Quality from the Patient's Perspective model, the patient judges the different domains in two dimensions: perceived reality and subjective importance. The Quality, Satisfaction, Performance model uses a multivariate analysis to capture the patient's priorities. Four hundred and sixty forms for each model were distributed to a random sample of patients at the Department of Obstetrics and Gynecology at Karolinska Hospital. MAIN MEASURES: The quality factors 'treatment by the nurse', 'participation', 'information', 'environment' and 'accessibility' were measured. RESULTS: On both forms, 'medical care', 'treatment by the doctor' and 'access to nursing treatment' received high scores in perceived reality' while 'accessibility' and 'participation' received low scores. 'Subjective importance' measured directly and indirectly, respectively, in the two models showed high values for 'medical care' and 'treatment by the doctor'. CONCLUSION: The advantages of the Quality from the Patient's Perspective model are that it has a comprehensive and solid question bank. The Quality, Satisfaction, Performance model's advantage is its immediate usefulness and its clear graphic presentation. An integration and further development of these two approaches may prove useful.

[Patient preferences or cost-effectiveness? Priorities are highly affected by introduction of economic dimension]. / Patientönskemål eller kostnadseffektivitet? Prioriteterna påverkas högst påtagligt då en ekonomisk dimension införs.

In recent years various methods to measure patient satisfaction have been applied as part of quality improvement programmes in the health services. However, the statistical quality as well as the applicability and change-orientation of the methods have been questioned. Furthermore, most methods pay no attention to economic aspects. Even a methodologically well-founded measurement of patient satisfaction may lead to wrong conclusions unless economic consequences are taken into consideration. It is possible to carry out an integrated analysis that includes patient preferences as well as economic aspects.

Estimating the effect of cesarean section rate on health outcome. Evidence from Swedish hospital data.

This paper tests the null hypothesis of a zero effect of cesarean section rate on health outcome against the alternative of a positive effect. Using data from 59 hospitals in Sweden from 1988-92, we specify two separate linear regression models for health outcome, one with perinatal mortality, and the other with rate of asphyxia, as dependent variable. We estimate the models by single-year cross-section regressions and as pooled data systems. The null hypothesis cannot be rejected, i.e., we do not find any significant positive effect of cesarean section rate on health outcome. Thus, we conclude that an increase in cesarean section rate does not imply lower perinatal mortality or lower rate of asphyxia. This in turn indicates that the minimum cesarean section rate is optimal.

Econometric analysis of variation in cesarean section rates. A cross-sectional study of 59 obstetrical departments in Sweden.

The objective of this study was to explain the variation in cesarean section rates among hospitals (obstetrical departments) in Sweden, and to discuss its potential economic consequences. Using data from The Swedish Medical Birth Registry 1991, we made a cross-sectional study of the cesarean section rate at the departmental level. We identified some 20 determinants, demand-related as well as supply-related. A general model including all these regressors was specified. After reducing this model, we were able to explain about one-quarter of the variation. We conclude that the large variation in cesarean section rates indicates inefficiency, due mainly to overutilization, but perhaps also underutilization. It is difficult to calculate the economic consequences or the welfare loss to society. We estimated an additional cost for unnecessary cesarean sections of 13-16 million Swedish crowns (SEK) per year.

Change-oriented patient questionnaires--testing a new method at three departments of ophthalmology.

The use of patient questionnaires has increased widely in recent years. Their purpose, to incorporate patient perspectives into the orientation and design of health care, is, of course, commendable. However, the survey methods themselves have been less adequate, both in terms of validity and reliability, and with respect to the potential for using the results to improve the quality of health care. Presents a pilot study at three departments of ophthalmology in Sweden, involving a new method which meets reasonable demands for validity and reliability, and is explicitly change-oriented.

Value for money? A contingent valuation study of the optimal size of the Swedish health care budget.

The contingent valuation method has been developed in the environmental field to measure the willingness to pay for environmental changes using survey methods. In this exploratory study the contingent valuation method was used to analyse how much individuals are willing to spend in total in the form of taxes for health care in Sweden, i.e. to analyse the optimal size of the 'health care budget' in Sweden. A binary contingent valuation question was included in a telephone survey of a random sample of 1260 households in Sweden. With a conservative interpretation of the data the result shows that 50% of the respondents would accept an increased tax payment to health care of about SEK 60 per month ($1 = SEK 8). It is concluded that the results indicate that the population overall thinks that the current spending on health care in Sweden is on a reasonable level. There seems to be a willingness to increase the tax payments somewhat, but major increases does not seem acceptable to a majority of the population.

Variations in resource utilization--the role of medical practice and its economic impact.

Several studies have indicated that differences in medical practice are often an important factor behind variations in resource utilization. 'Practice', in medical contexts, is used as a comprehensive expression for what is regarded to be adequate care, considering science and proven experience, as well as present resources, demography, organization, and other given conditions. However, experience shows that routines and practice, even under similar conditions (resources, organization, etc.) often vary significantly among departments within the same medical discipline. In this more restricted sense, variations in practice might depend on different--more or less well-founded--opinions among physicians concerning what constitutes appropriate length of stay, level of care, and technology. With examples from some specialties (e.g. general surgery, obstetrics and gynecology), we demonstrate this 'model' and the economic impact of practice variations. Our conclusion is that there are opportunities for achieving greater benefit from existing resources, i.e. increasing efficiency, through reallocation and alternative utilization of resources, altered practice.

Hypertension case-finding in primary health care. Experience from the Skaraborg Hypertension Project.

This study evaluates the efficacy of a hypertension case-finding program. During office hours (8.00 am to 5.00 pm weekdays), all patients visiting a Swedish primary health care center, had their blood pressure recorded using an automatic equipment. This was made irrespective of the reason for the visit. Analysis of a record sample showed that 56 +/- 4% (95% confidence) of the 40-69 year-old fraction of the population (N = 5,806) served by the center attended the center during a two-year period. Fifty-two percent (N = 3,025) had their blood pressure checked and one percent (N = 65) fulfilled the criteria for hypertension (greater than 170/greater than 105 mmHg at three different times if aged 40-60 years; greater than 180/greater than 110 mmHg greater than 60 years). We conclude that case-finding for hypertension has low efficacy when performed in day-time primary health care.

Economic evaluation of a Swedish medical care program for hypertension.

A Hypertension Care Program, developed in cooperation between physicians and nurses in both primary care and at the hospitals in the area, was implemented in the Skaraborg County, Sweden in 1977. The Program, which provided for the establishment of hypertensive clinics at outpatient units and referral to medical clinics, was clearly aimed towards giving nurses increased responsibility for hypertensive care. The Skaraborg Program has been evaluated from several important perspectives. A terminal population study showed better blood pressure control among the hypertensive patients within the program area than within the control area. The economic evaluation indicates that hypertensive care according to the Program is somewhat less resource demanding than conventional hypertensive care. Since the medical effects of hypertensive care were improved without increased demand for resources, the structured Care Program was more cost-effective than conventional care.