“WHY IS HE NOT SMILING?” DENTAL COSTS STUDY PHASE ONE

“WHY IS HE NOT SMILING?” DENTAL COSTS STUDY PHASE ONE FINAL

REPORT

August 2008

Health Issues Centre Inc. Level 5, Health Sciences 2 LA TROBE UNIVERSITY VIC 3086  (03) 9479 5827 Email:

Fax: (03) 9479 5977

[email protected] Websites:

www.healthissuescentre.org.au www.participateinhealth.org.au

We suggest that this report be cited as follows: Horey, D., Naksook, C., McBride, T. and Calache, H., 2008, Why is He not Smiling: the Dental Costs Study Final Report. Health Issues Centre, Melbourne.

TABLE OF CONTENTS

PAGE NO:

ACKNOWLEDGEMENTS

5

EXECUTIVE SUMMARY

8

PART A: 1.

2.

14

1.1 1.2 1.3 1.4 1.5 1.6

14 14 15 16 20 20

Rationale for the Study Broader Context Victoria’s Public Dental Service Dianella Community Health Impacts of Oral Health Status Dental Cost Study

RESEARCH PLAN

22

2.1 2.2 2.3 2.4 2.5 2.6

22 22 23 23 25 26

Aims Research Method Sample Size Data Sources Recruitment Reliability

RESULTS

ALL STUDY PARTICIPANTS

Overview 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8

4.

14

INTRODUCTION

PART B: 3.

BACKGROUND

Limitations of the Study Response to Recruitment Who Took Part? Use of Dental Services Oral Health Status General Health Status Proposed Treatment and Costs Key Issues

COMPARISON OF WAITING TIMES

Overview 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8

Response to Recruitment Demographic Profile Oral Health and General Health Clinical Outcomes Oral Health Impact Profile Costs of Proposed Treatment and the Treatment Plans Impact of Proposed Treatment on Number of Functional Teeth Key findings

“Why is He Not Smiling?” Dental Costs Study Phase One Final Report Health Issues Centre, August 2008

28 28

28 30 31 32 34 36 43 46 47

48

48 49 49 51 54 59 59 61 62

3

5.

QUALITATIVE DATA FROM THE QUESTIONNAIRE

Overview 5.1 5.2 5.3 5.4 5.5

6.

7.

Oral Health and General Health Oral Health and Quality of Life Barriers to Public Dental Services The Consequences Key Issues

64

64 65 66 68 70 71

NON PARTICIPANT SURVEY

74

6.1 6.2 6.3 6.4

Survey Method Responses Why People Did Not Take Part Key Issues

74 74 75 78

DISCUSSION AND CONCLUSION

80

7.1

80

Key Findings

8.

REFERENCES

88

9.

APPENDICES

92

APPENDIX ONE: APPENDIX TWO: APPENDIX THREE: APPENDIX FOUR: APPENDIX APPENDIX APPENDIX APPENDIX APPENDIX APPENDIX

FIVE: SIX: SEVEN: EIGHT: NINE: TEN:

APPENDIX ELEVEN: APPENDIX TWELVE:

STUDY PROTOCAL COMPLETE LIST OF DATA ITEMS DIANELLA’S LETTER OF OFFERING ON AN APPOINTMENT HEALTH ISSUES CENTRE’S LETTERS EXPLAINING THE STUDY PROJECT INFORMATION SHEET CONSENT FORM NON PARTICIPANT SURVEY INTERVIEW QUESTIONNAIRE RELIABILITY TESTING PROPOSED TREATMENT ITEM NUMBERS BY TREATMENT TYPE AND WAITING TIME ADDITIONAL TABLES FOR CHAPTER 3 MEAN COSTS, NUMBER OF PROPOSED TREATMENT BY TYPE AND BY GROUP

“Why is He Not Smiling?” Dental Costs Study Phase One Final Report Health Issues Centre, August 2008

92 98 100 101 103 107 108 109 117 118 118 127 132

4

ACKNOWLEDGEMENTS Health Issues Centre, in collaboration with Dental Health Services Victoria and Dianella Community Health, conducted the study with funding support from the Department of Human Services Victoria, the Victorian Health Promotion Foundation and Dental Health Services Victoria. The Project Reference Group provided advice and support. It comprised: Mark Sullivan Dr Sachidanand Raju Nella Larubina Dr Hanny Calache Dr Rodrigo Marino Frank McNeil Judith Cassar Tony McBride Dell Horey Charin Naksook

Dianella Community Health Dianella Community Health Dianella Community Health Dental Health Services Victoria University of Melbourne Consumer representative Consumer representative (until August 2006) Health Issues Centre Health Issues Centre (until December 2007), Australian Institute for Primary Care Health Issues Centre

Additional advice was sought from: Professor John Spencer Adelaide University Dr Jane Harford Adelaide University Dr Charles Livingstone Monash University Pauline Brophy, Zahra Lassi and Helen Walls conducted most of the interviews. Martin Whelan of Dental Health Services Victoria provided technical assistance in the data collection. Dr Rodrigo Marino of the University of Melbourne assisted with the reliability testing analysis. We would like to acknowledge the invaluable contributions of all staff members at Dental Practice, Dianella Community Health, especially Nella Larubina and reception staff who assisted with recruitment of study participants; Dr Rosemary Phillipos, Dr Thanh Nguyen, Angela Black and clinical staff who conducted dental examinations for all study participants. We are especially grateful to the public dental patients at Dianella Community Health who kindly took part in the study. Dell Horey, Charin Naksook, Tony McBride and Hanny Calache wrote the report.

“Why is He Not Smiling?” Dental Costs Study Phase One Final Report Health Issues Centre, August 2008

5

“Why is He Not Smiling?” Dental Costs Study Phase One Final Report Health Issues Centre, August 2008

6

“Why is He Not Smiling?” Dental Costs Study Phase One Final Report Health Issues Centre, August 2008

7

EXECUTIVE SUMMARY The Dental Costs Study (DCS) is the first comprehensive study of the comparative costs of public dental care in Victoria. It investigated the costs of delayed dental treatment for users of public dental health clinics1 among two groups of dental patients. One group was on the waiting list for more than two years (Group A) and the other group was on the waiting list for two to four months (Group B). The study also explored the impact of delayed dental treatment on health and social behaviours. Health Issues Centre, in collaboration with Dental Health Services Victoria and Dianella Community Health, conducted the study at Dianella Community Health, Broadmeadows, between September 2006 and February 2007. Funding for the study was provided by the Department of Human Services Victoria, the Victorian Health Promotion Foundation and Dental Health Services Victoria. Comprehensive data were collected through a mixed method approach combining clinical data with structured interviews and data from non-participants. The costs measured in this study are based on proposed treatment plans, and do not include the costs of emergency dental services or co-payments. This study is by no means an evaluation of Dianella’s staff performance or the quality of services they provide. Two hundred and forty-six (246) public dental patients took part in the study. One hundred and thirty (130) had been on the waiting list for two years or more (Group A), and 116 on the waiting list for two to four months (Group B). Key findings Cost of proposed dental treatment The costs of proposed dental treatment for people in the study ranged from $46 to more than $4,000, with an average cost of $924. This average cost is higher than expected, and almost three and a half times higher than the average cost of general dental treatment for public patients in Victoria of $271.2 Nearly 80% of people in the study had proposed treatment costs greater than the state’s average. This difference raises concerns about whether low income Australians receive all the dental treatment they require and whether actual treatment differs markedly from proposed treatment. There are also issues about the variation in need among those seeking public dental services and how this variation is managed. The mean costs of proposed dental treatment were slightly lower for people in the short-waiting Group B compared with those in the longer-waiting Group A ($912 compared with $936). Although this difference of less than 3% is statistically significant, it is not financially significant (see Section 4.6). The calculation of the proposed costs of treatment did not include costs associated with dental treatment from emergency dental services, or private dentists, undertaken while people were waiting for an offer of treatment from the public dental clinic. 1

For details about the Dental Costs Study, go to www.healthissuescentre.org.au\projects\index.asp The 2006-2007 figure from Clinical Analysis and Evaluation, DHSV. As with the study’s average, it does not include dental voucher and emergency services.

2

“Why is He Not Smiling?” Dental Costs Study Phase One Final Report Health Issues Centre, August 2008

8

Distribution of cost and types of treatment A major finding of the study was the distribution of costs for the proposed treatment types. Overall, only 8% of all proposed treatment costs were allocated to preventive care. The smallest proportion of costs (2%) was for the proposed management of periodontal disease, even though more than a fifth of the study population (22%) showed evidence of advanced periodontal disease and more than six in 10 showed evidence of calculus (that indicates a need for scaling and cleaning; 61%). More than one-third of the proposed costs were for fillings or restorative treatment (37.7%), and nearly a quarter of proposed costs were for dentures (see Section 3.7). Differences in the proposed costs between the two groups were apparent in all types of treatment apart from preventive care. The average cost for the proposed treatment among the longer-waiting Group A was higher for diagnostic services and periodontal, endodontic and restorative treatments, and for dentures. Costs for oral surgery and other services—mainly interpreter services—were higher for the shorter-waiting Group B (see Section 4.6). Oral health We found strong evidence of continuing inequalities in oral health status. The majority of study participants had a number of indicators of poor oral health. Compared with the results of the National Survey of Adult Oral Health (NSAOH) (2004–2006;Slade, Spencer et al. 2007), more adults in this study had: •

Inadequate dentition—20 or fewer natural functional teeth (51% DCS vs 11% NSAOH)

•

High levels of gum disease—advanced gum disease (22.2% vs 2.4%) and moderate gum disease (53.6% vs 20.5%).

Only nine (3.6%) out of 246 people in the study had at least 20 natural functional teeth and all associated supporting periodontal tissues (gums) healthy. More than 40% of people in this study reported they had visited a dentist in the previous 12 months (42.9%), about two-thirds the rate of dentate Australian adults (Slade, Spencer et al. 2007). The majority of these visits for people in this study were for emergency dental treatment (57% [see Table 4.3]), whereas nationally only 38 percent of dental visits are for emergency care (Slade, Spencer et al. 2007). Some differences in oral health between the two groups were apparent. Clinical examination of the two groups found that the longer-waiting Group A presented with a greater proportion of gum disease (87.7% vs 79.3%, p