Major clinical events and healthcare resource use among patients with long-chain fatty acid oxidation disorders in the United States: Results from LC-FAOD Odyssey program

Major clinical events (MCEs) related to long-chain fatty acid oxidation disorders (LC-FAOD) in triheptanoin clinical trials include inpatient or emergency room (ER) visits for three major clinical manifestations: rhabdomyolysis, hypoglycemia, and cardiomyopathy. However, outcomes data outside of LC-FAOD clinical trials are limited. The non-interventional cohort LC-FAOD Odyssey study examines data derived from US medical records and patient reported outcomes to quantify LC-FAOD burden according to management strategy including MCE frequency and healthcare resource utilization (HRU). Thirty-four patients were analyzed of which 21 and 29 patients had received triheptanoin and/or medium chain triglycerides (MCT), respectively. 36% experienced MCEs while receiving triheptanoin versus 54% on MCT. Total mean annualized MCE rates on triheptanoin and MCT were 0.1 and 0.7, respectively. Annualized disease-related inpatient and ER events were lower on triheptanoin (0.2, 0.3, respectively) than MCT (1.2, 1.0, respectively). Patients were managed more in an outpatient setting on triheptanoin (8.9 annualized outpatient visits) vs MCT (7.9). Overall, this shows that those with LC-FAOD in the Odyssey program experienced fewer MCEs and less HRU in inpatient and ER settings during triheptanoin-treated periods compared with the MCT-treated periods. The MCE rate was lower after initiation of triheptanoin, consistent with clinical trials.

Estimation of Health Utility Scores for Glycogen Storage Disease Type Ia

BACKGROUND

Glycogen Storage Disease Type Ia (GSDIa) is a rare genetic metabolic disorder characterized by hypoglycemia, hepatomegaly, growth failure, and possible seizures/death. Patients frequently consume cornstarch to maintain blood glucose. Evidence demonstrating the impact of GSDIa on health-related quality of life (HRQoL) is lacking. This study aims to understand the burden of GSDIa by obtaining utility values for economic appraisals.

METHODS

A targeted literature review and interviews with experts (n = 4) and caregivers (n = 4) informed the development of health state vignettes describing different GSDIa severities by age and level of hypothetical treatment (i.e., gene therapy) response. Health states reflecting caregivers' experiences were also developed. A convenience sample of the UK general public completed a time trade-off (TTO) exercise. Scores conceptually varied from 0 (dead) to 1 (full health). States were also rated using a visual analog scale (VAS) and the EQ-5D-5L. Data were descriptively summarized.

RESULTS

One hundred participants completed the exercise (male: 48%; mean age: 42 years). Scores were lowest for the adolescent pre-treatment state (TTO = 0.38). Large increments in HRQoL were observed for the response (adult: TTO = 0.86; child: TTO = 0.84) and complete response (adult and child: TTO = 0.94) hypothetical treatment response states. Caregiver values were lowest for the pre-treatment state (TTO = 0.57) and highest for the complete response state (TTO = 0.95). VAS and EQ-5D-5L scores followed a similar pattern.

CONCLUSION

This study found an HRQoL burden on GSDIa patients and caregivers, with potential large improvement from a hypothetical treatment. These findings may be useful for families, clinicians, regulatory agencies, and in therapy economic evaluations.

Hospitalisations due to pulp and periapical conditions in Australian children from 1998-99 to 2017-18

OBJECTIVE

To assess the demographic and time trends in hospitalisation rate for Pulp and Periapical Diseases (P&PDs) over 20-years (1998-99 to 2017-18), amongst children and adolescents (under age 19 years) in all states and territories of Australia. P&PDs are considered potentially preventable, with the possibility of them resulting in emergency presentations if timely treatment is not provided. They can result in treatment under general anaesthesia, which is costly.

DESIGN

Retrospective analysis of hospitalisation for pulp and periapical diseases.

SETTING

Public and private hospitals across Australia.

MAIN OUTCOME MEASURES

The number of hospitalisations (measured using the number of separations or cases of hospital admission) for all pulp and periapical diseases by age-group.

RESULTS

There were about 40,000 hospitalisations regarding P&PDs over the 20 years among Australian children under 19 years old. The rate of admissions ranged from means of 28.5 to 44.1 per 100,000 population. The number of admissions increased over 20 years for all children, except those younger than 4 years. Children aged 5-9 years had the highest rate of admissions and, more days in hospital per admission than other age groups. Most children only had one-day admissions.

CONCLUSION

Pulp and periapical diseases hospitalisation rates have increased over two decades. Additional approaches to improve child dental health in Australia need to be considered.

Gall bladder torsion masquerading as appendicitis in a teenage boy

SUMMARY

This report describes acute gallbladder torsion in a previously healthy 16-year-old male. The patient presented with acute right-sided abdominal pain in keeping with acute appendicitis and was taken for a diagnostic laparoscopy where an intraoperative diagnosis of gallbladder torsion was made. This case highlights a very rare surgical presentation in an uncommon patient profile. It highlights the benefit of diagnostic laparoscopy in a resource-constrained facility.

Understanding the impact of long-chain fatty acid oxidation disorders for patients and caregivers

Long-chain fatty acid oxidation disorders (LC-FAOD) are a group of rare, autosomal recessive genetic disorders that impair conversion of long-chain fatty acids into energy. Here we describe the impact of LC-FAOD in terms of effects on work and school, absenteeism and presenteeism at work, importance of symptoms, physical activity, participation in social activities, and quality of life (QoL). A convenience sample of adults (≥18 years) and caregivers of patients with LC-FAOD was invited to take the online survey (Confirmit). To be included, patients must have been receiving medical care from a healthcare provider for their LC-FAOD, and caregivers must not have been compensated for their care. Degree of physical activity, represented by metabolic equivalents (METs), was calculated using the NHANES Physical Activity Questionnaire. Absenteeism and presenteeism at work were calculated using the WHO Health Productivity Questionnaire. QoL was assessed using the 12-Item Short Form of the Medical Outcomes Survey. Significance was assessed using two tailed independent sample t-tests and z-tests at α = 0.1. Fourteen adults and 30 caregivers of LC-FAOD patients (answering for 37 patients) answered the survey (51 unique respondents). 59.2% of LC-FAOD patients experienced effects on their schooling due to LC-FAOD. 84.2% of working patients experienced effects on their work due to LC-FAOD. 70% of caregivers experienced effects on their work due to their child's LC-FAOD. Unique respondents report that muscle weakness (69%), physical fatigue (49%), and rhabdomyolysis (39%) are the most impactful symptoms of LC-FAOD. Adults (n = 14) scored significantly below the normalized average (50) on both physical (34.51, p < 0.001) and mental (45.27, p = 0.04) component scores of the SF-12 health-related quality of life measure. LC-FAOD impart a high disease impact on patients and their caregivers. In particular, symptoms relating to energy production were rated as highly impactful and limiting. Activities that may be considered normal for many people can prove to be very difficult or impossible for respondents with LC-FAOD, with respondents reporting lower physical and mental health-related quality of life measures than the average American.

•

LC-FAOD has a measurable impact on patient and caregiver education and employment (83/85).

•

Muscle weakness was the most impactful symptom of LC-FAOD on individuals' lives (82/85).

•

Physical and mental health were significantly lower in individuals with LC-FAOD (82/85).

Estimating the Prevalence of Rare Diseases: Long-Chain Fatty Acid Oxidation Disorders as an Illustrative Example

Introduction

Determining the epidemiology of disease is critical for multiple reasons, including to perform risk assessment, compare disease rates in varying populations, support diagnostic decisions, evaluate health care needs and disease burden, and determine the economic benefit of treatment. However, establishing epidemiological measures for rare diseases can be difficult owing to small patient populations, variable diagnostic techniques, and potential disease and diagnostic heterogeneity. To determine the epidemiology of rare diseases, investigators often develop estimation models to account for missing or unobtainable data, and to ensure that their findings are representative of their desired patient population.

Methods

A modeling methodology to estimate the prevalence of rare diseases in one such population—patients with long-chain fatty acid oxidation disorders (LC-FAOD)—as an illustrative example of its applicability.

Results

The proposed model begins with reliable source data from newborn screening reports and applies to them key modifiers. These modifiers include changes in population growth over time and variable standardization rates of LC-FAOD screening that lead to (1) a confirmed diagnosis and (2) improvements in standards of care and survival estimates relative to the general population. The model also makes necessary assumptions to allow the broad applicability of the estimation of LC-FAOD prevalence, including rates of diagnosed versus undiagnosed patients in the USA over time.

Conclusions

Although each rare disease is unique, the approach described here and demonstrated in the estimation of LC-FAOD prevalence provides the necessary tools to calculate key epidemiological estimates useful in performing risk assessment analyses; comparing disease rates between different subgroups of people; supporting diagnostic decisions; planning health care needs; comparing disease burden, including cost; and determining the economic benefit of treatment.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12325-022-02186-2.

Size estimation of unerupted canines and premolars using various independent variables: a systematic review

INTRODUCTION

Prediction of unerupted permanent teeth is an essential part of orthodontic diagnosis and treatment planning. This prediction is done by mixed dentition space analysis based on the estimation of mesiodistal dimensions of unerupted permanent canine and premolars from already erupted permanent teeth. Permanent mandibular incisors are most commonly used for prediction. Recent literature reveals that mandibular incisors are not accurate predictors and other independent variables have been introduced to make a more accurate and precise prediction. The objective of this paper was to evaluate the literature in light of a variety of independent variables and their predictive accuracy.

METHODS

Electronic databases such as MEDLINE, PubMed, Scopus, Embase, Web of Science, CINAHL Plus were searched to identify articles published until September 2021.

RESULTS

The search resulted in a total of 1098 articles, of which 24 papers met our inclusion criteria and were included in this review. Articles using permanent mandibular incisors only as a predictor were excluded during the eligibility assessment. The results show that various independent variables including mesiodistal and vestibulo-oral dimensions of permanent maxillary and mandibular incisors and molars, molar basal arch length, intermolar distance, maxillary and mandibular arch and gender have been used as predictors to more accurately determine mesiodistal width of unerupted canine and premolars in different populations.

CONCLUSION

Ethnic tooth size variations strongly emphasize the need to determine which independent variable gives a more accurate prediction of unerupted permanent teeth to develop a population-specific prediction model. This will play a significant role in managing space problems and developing malocclusions.

Qualitative evaluation of the symptoms and quality of life impacts of long-chain fatty acid oxidation disorders

BACKGROUND

Long-chain fatty acid oxidation disorders (LC-FAOD) are a group of rare autosomal-recessive genetic disorders characterized by metabolic deficiencies in which the body is unable to convert long-chain fatty acids into energy. To date, however, there is limited understanding of the patient experience of LC-FAOD.

METHODS

The symptoms, observable signs, and quality of life (QoL) impacts associated with LC-FAOD were explored via a focus group (n = 8) and semi-structured interviews (n = 6) with patients and caregivers of patients with LC-FAOD, and interviews (n = 4) with expert clinicians. Data were analyzed via thematic analysis and summarized in a conceptual model.

RESULTS

Participants reported a wide range of signs and symptoms associated with LC-FAOD, broadly categorized as musculoskeletal, endocrine/nutritional/metabolic, neurological, gastrointestinal/digestive, sensory, cardiovascular, respiratory, urological, and constitutional. LC-FAOD were reported to have a significant impact on various aspects of patients' lives including physical functioning, participation in daily activities, emotional/psychological wellbeing, and social functioning. Lifestyle modifications (such as diet and exercise restrictions) were necessary because of the condition. Symptoms were typically episodic in presentation often arising or exacerbated during catabolic conditions such as prolonged exercise, fasting, physiological stress, and illness/infection. Symptoms were also commonly reported to lead to emergency room visits, hospitalization, and clinical complications.

CONCLUSION

LC-FAOD have a considerable impact on patients' lives. There is a high degree of concordance in the signs, symptoms, and impacts of LC-FAOD reported by patients, caregivers, and clinicians; however, there were many symptoms and impacts that were only reported by patients and caregivers, thus demonstrating that insights from patient/caregiver experience data are integral for informing medical product development and facilitating patient-centered care.

Oral health education and prevention strategies among remote Aboriginal communities: a qualitative study

BACKGROUND

The delivery of effective oral health promotion strategies is essential to improving oral health outcomes among remote Aboriginal communities. This study aimed to explore the perceptions and attitudes of Aboriginal Australians living in remote Kimberley communities towards oral health education and disease prevention.

METHODS

Semi-structured interviews and yarning circles were carried out following purposive sampling of Aboriginal adults living in the East Kimberley region of Western Australia.

RESULTS

A total of 80 community members participated in the yarning process. School-based oral health promotion and community-driven restrictions on the sale of sugary food and drink were seen as positive strategies in improving oral health. Lifestyle changes brought about by modernity, internet availability and fixed community stores were perceived to create new challenges and shift the priorities for those living in remote communities.

CONCLUSIONS

Community-based yarning may better inform future oral health strategies in the Kimberley. A neoliberal approach of shifting responsibility onto the individual ignores the complex social inequities faced by Aboriginal people living in remote communities where macro-level determinants such as remoteness, food security and education significantly influence decisions around diet and oral health.

Management of dental emergencies amongst Australian general medical practitioners - A case-vignette study

BACKGROUND

In Australia, because of inequity in dental service accessibility and affordability, patients can see general medical practitioners (GPs) for acute dental conditions.

METHODS

This cross-sectional study consisted of surveys distributed to the board registered GPs practising in Australia. The main outcome measures included statistical analysis of GPs managing different dental emergency scenarios and their confidence and expectations in managing dental emergencies.

RESULTS

A total of 425 GPs participated in the study. The sample primarily consisted of GPs practising in metropolitan clinics (n = 315). Most participants reported that they would refer to the dentist for mobilized tooth (n = 402). There was a negative correlation between GPs with 5-29 years of experience and traumatized tooth management (P < 0.05). GPs aged between 40 and 49 years were more inclined to treat patients with mobilized teeth [Multivariate (MV): 0.42(0.09-0.74)]. However, GPs with 0-5 years of experience were less likely to manage patients with dental abscess [MV: -0.52(-0.80 to -0.24)].

CONCLUSION

Most GPs referred dental emergencies to dentists. GP management of dental emergencies were predominantly palliative. Therefore, opportunities for collaborative practice models amongst GPs and dentists may be needed to bridge the gap in the regional and remote locations.

Innovative methodology to guide planning of dental workforce distribution: a GIS-based study in Nepal

OBJECTIVES

To build a predictive model based on the distribution pattern of dentists and population in selective districts of Nepal.

METHOD

Cross-sectional descriptive study conducted using secondary data from the census report and available dentist data of Nepal. Population data were obtained from the most recently available census. For dentists' data, a literature search was carried out in the databases such as PubMed, Google scholar, One Search and Medline. All data were extracted from the integrated database in the Geographic Information System (GIS), and a predictive model was built.

RESULTS

Overall, there was an uneven distribution of dentists in Nepal. When the distribution of dentists was compared with the population clusters, it was found that the slope of the population growth was below or equal to (≤) 20,000 for three provinces (2, 6, and 7), which means that lower numbers of dentists are available with respect to population density in these provinces. The slope was above 50,000 for province 3, and the number of dentists was almost half of the total nationwide. The number of dentists correlated with population clusters.

CONCLUSION

There are substantial disparities in the distribution of dentists in Nepal. Dentists were distributed relative to higher population clusters and were unevenly distributed. The Nepal government should make necessary arrangements to address the need for the human workforce in resource-limited settings. The methods used in this study could be applied globally, as the data used are available for most countries.

Current practices of Western Australian general dentists regarding management of patients on anticoagulant/antiplatelet therapy

PURPOSE

Currently, there are little to no published studies outlining general dentists' knowledge in the management of patients on anticoagulant/antiplatelet therapies in Australia. The aim of this study was to investigate the current practices of Western Australian (WA) general dentists with regards to dental management of patients taking anticoagulants/antiplatelets.

MATERIALS AND METHODS

WA dentists were invited to undertake a survey to investigate their knowledge on the management of patients taking anticoagulant/antiplatelet. The questionnaire provided to WA general dentists consisted of pre-extraction advice on patients (direct oral anticoagulants [DOACs], antiplatelets, warfarin, dual antiplatelets and antiplatelet/anticoagulant). Results were analysed using descriptive statistics as well as chi-square tests.

RESULTS

Of the 89 participants, 40.5% had <5 years of general dental experience. Most WA general dentists (64%-71%) responded with 'no change' when performing extractions on patients on DOACs, antiplatelet therapy, warfarin, dual antiplatelets and antiplatelets/anticoagulants (P = 0.00). Furthermore, dentists with 6-10 years of experience were more likely to cease antiplatelet for 24 h before extractions (P < 0.05). Dentists who extracted 10-30 teeth per month were likely to stop antiplatelets and DOACs for more than 48 h compared to other groups (P < 0.05).

CONCLUSION

Most WA dentists would not cease anticoagulant/antiplatelet therapy when undergoing dental extractions.

Correction to: Cost-effectiveness evaluation of the 10-valent pneumococcal non-typeable Haemophilus influenzae protein D conjugate vaccine for children in Taiwan

An amendment to this paper has been published and can be accessed via the original article.

US cost-effectiveness and budget impact of point-of-care NAAT for streptococcus

OBJECTIVES

In the United States, approximately 12 million individuals seek medical care for pharyngitis each year, accounting for about 2% of ambulatory care visits. Although the gold standard for diagnosing group A streptococcus (GAS) is culture, it is time intensive. Rapid antigen detection tests (RADT) with or without culture confirmation are commonly used instead. Although RADT provide results quickly, they generally have lower test sensitivity. Recently, point-of-care nucleic acid amplification tests (POC NAAT) have emerged. This study evaluates the cost-effectiveness and budget impact to the US payer of adopting POC NAAT.

STUDY DESIGN

This study was a cost-effectiveness analysis, with costs and outcomes calculated via a decision tree.

METHODS

A decision-tree model quantified costs and outcomes associated with a GAS diagnostic strategy using POC NAAT compared with RADT + culture confirmation. Model inputs were derived from the published literature. Model outputs included costs and clinical effects: quality-adjusted life-days lost, GAS and antibiotic complications, number of patients appropriately treated, and antibiotic utilization. Sensitivity and scenario analyses were performed.

RESULTS

Base-case analysis projected that a POC NAAT strategy would cost $44 per patient compared with $78 for RADT + culture. Compared with RADT + culture, POC NAAT would increase the number of appropriately treated patients and avert unnecessary use of antibiotics. The budget impact of POC NAAT was -0.4% relative to current budget over 5 years. Findings were robust in sensitivity analyses.

CONCLUSIONS

Our results suggest that POC NAAT would be less costly and more effective than RADT + culture; POC NAAT adoption may yield cost savings to US third-party payers. Access to POC NAAT is important to optimize GAS diagnosis and treatment decisions in the United States.

Cost-effectiveness evaluation of the 10-valent pneumococcal non-typeable Haemophilus influenzae protein D conjugate vaccine for children in Taiwan

Background

Streptococcus pneumoniae (S. pneumoniae) and non-typeable Haemophilus influenzae (NTHi) are substantial contributors to morbidity and mortality of diseases including invasive pneumococcal diseases (IPDs), pneumonia and acute otitis media (AOM) worldwide. In Taiwan, 10-valent pneumococcal polysaccharide and NTHi protein D conjugate vaccine (PHiD-CV) and 13-valent pneumococcal conjugate vaccine (PCV13) are licensed in children against pneumococcal disease. In addition to S. pneumoniae, clinical trials suggest efficacy of PHiD-CV against NTHi AOM. This study aims at evaluating the cost-effectiveness of a 2 + 1 schedule of PHiD-CV vs. PCV13 2 + 1 in the universal mass vaccination program of infants in Taiwan.

Methods

A published Markov cohort model was adapted to simulate the epidemiological burden of IPD, pneumonia and AOM for a birth cohort in Taiwan over 10 years. The probability of entering a specific health state was based on the incidence rate of the diseases. Only direct medical costs were included, and costs and outcomes were discounted annually. Vaccine efficacy assumptions were based on published data and validated by a panel of independent experts. Clinical, epidemiological, and serotype distribution data were based on locally published data or the National Health Insurance Research Database. Price parity of vaccines was assumed. Published pneumococcal disease-related disutility weights were used due to lack of local data. Incremental cost-effectiveness ratio was calculated and benchmarked against the recommended threshold in Taiwan. Extensive one-way sensitivity analysis, alternative scenarios and probabilistic sensitivity analysis were performed to test the robustness of the results.

Results

PHiD-CV would potentially reduce the number of NTHi-related AOM cases substantially and prevent comparable IPD and pneumonia-related cases and deaths compared to PCV13. Over a 10-year horizon, PHiD-CV is estimated to dominate PCV13, saving 6.7 million New Taiwan Dollars (NTD) and saving 21 quality-adjusted life years. The result was robust over a wide range of sensitivity analyses. The dominance of PHiD-CV was demonstrated in 90.5% of the simulations.

Conclusions

PHiD-CV 2 + 1 would provide comparable prevention of IPD, pneumonia cases and additional reduction of NTHi-AOM cases, and is considered dominant compared with PCV13 2 + 1 in Taiwan.

Improving Iraqi school dental services: A GIS-based study of service location optimisation

BACKGROUND

The United Nations (UN) estimated the population of Iraq in 2005 at almost 29 million, of which nearly 14 million were children aged 0-14 years. Iraq is aiming to improve child oral health, and subsequent child general health, through school dental services, offered by primary health care centres.

OBJECTIVE

To develop and test a GIS-based planning approach for the Hillah district of Iraq as a model for the rest of the country. All data were gathered from open sources.

SETTING

The city has 98 neighbourhoods, with a total child population of 368 274, occupying 161 Sq. km2, with 14 fixed primary health care dental clinics.

DESIGN

Accessibility zones were created using GIS, based on the ability of dentists to make their way to schools.

OUTCOME MEASURES

A total of 23 307 of 0-4 year-olds (14%) and 74 384 (45%) of 0-15 year-olds lived outside the accessibility zones.

RESULT

Areas where services are not available to the child population were identified, whether or not they attended primary schools.

CONCLUSION

Reforming the existing dental health services in Iraq can be achieved by careful planning and appropriate utilisation of health resources.

Incidental findings detected on cone beam computed tomography in an older population for pre-implant assessment

OBJECTIVES

The aim of this retrospective study was to record incidental findings in CBCT scans taken in an older population for pre-implant assessment, and to examine whether these findings would influence the intended dental implant placement.

METHODS

300 consecutive CBCT scans over the age of 40 years was carried out. The incidental findings were grouped into regions as follows: dentoalveolar structures, maxilla and mandible, paranasal sinuses, temporomandibular joint (TMJ), naso/oral-pharyngeal airway, cervical spine and neurovascular canals. The incidental findings are further categories into their significance towards the intended treatment plan.

RESULT

Incidental findings were noted on all of the scans. 555 incidental findings (1.85 findings/scan) were identified. The highest number of incidental findings was in the sinuses (34%), followed by dentoalveolar structures (31%), nasal/oral-pharyngeal airway (12%), maxilla and mandible (10%), TMJ (6%), cervical spine (4%) and neurovascular canals (3%). A total of 37% of findings required follow-up. In 12% of cases detection of the incidental findings lead to amendment or abortion of the intended implant treatment plan.

CONCLUSION

Incidental findings within and beyond the region of interest are common in CBCT scans. The numbers of incidental findings per scan in an older population is higher than in a younger population.

Relationship Between Patient Characteristics and Number of Procedures as well as Length of Stay for Patients Surviving Severe Burn Injuries: Analysis of the American Burn Association National Burn Repository

This study establishes important, national benchmarks for burn centers to assess length of stay (LOS) and number of procedures across patient profiles. We examined the relationship between patient characteristics such as age and total body surface area (TBSA) burned and number of procedures and LOS in the United States, using the American Burn Association National Burn Repository (NBR) database version 8.0 (2002–2011). Among 21,175 surviving burn patients (TBSA > 10–60%), mean age was 33 years, and mean injury size was 19.9% TBSA. Outcomes included the number of debridement, excision, autograft procedures, and LOS. Independent variables considered were: age (linear, squared, and cubed to account for nonlinearity), TBSA, TBSAs of partial-thickness and mixed/full-thickness burns, sex, hospital-acquired infection, other infection, inhalation injury, and diabetes status. Regression methods included a mixed-effects model for LOS and ordinary least squares for number of procedures. A backward stepwise procedure (P <0.2) was used to select variables. Number of excision and autografting procedures increased with TBSA; however, this relationship did not hold for debridement. After adjusting for sex, age, and comorbidities, predicted LOS for adults (18+) was 12.1, 21.7, 32.2, 43.7, and 56.1 days for 10, 20, 30, 40, and 50% TBSA, respectively. Similarly, predicted LOS for pediatrics (age < 18) was 8.1, 18.8, 33.2, 47.6, and 56.1 days for the same TBSA groups, respectively. While average estimates for adults (1.12 days) and pediatrics (1.01) are close to the one day/TBSA rule-of-thumb, consideration of other important patient and burn features in the NBR can better refine predictions for LOS.

The distribution of dentists in Australia Socio-economic profile as an indicator of access to services

OBJECTIVES

Analyse the dentist to population ratio relative to socio-economic profile to identify areas of workforce shortages and inform the policy direction of workforce recruitment strategies and public dental service planning.

METHODS

The suburb, state and postcode of dentists listed on the public access register of the Australian Health Practitioner Regulation Agency were geocoded by latitude and longitude and added to a map of Australia built on Australian Bureau of Statistics (ABS) Statistical Area 2 (SA2) census districts. Population data detailing the relative socio-economic disadvantage of each Statistical Area 1 (SA1) within each SA2 was superimposed on the map and used to calculate the number of dentists per 100 000 population relative to level of socio-economic disadvantage as defined by the ABS Socio-Economic Index for Areas, (SEIFA) Index of Relative Socio-economic Disadvantage (IRSD). The results were reported according to state and territory, and the Accessibility and Remoteness Index of Australia (ARIA+).

RESULTS

The dentist to population ratio was lower in areas of disadvantage within major cities. All regions outside major cities had population cohorts with dentist to population ratios below the 65 dentists per 100 000 benchmark, conservatively estimated to be the minimum required for reasonable access to services.

CONCLUSION

There is an inequity in the distribution of dentists relative to the socio-economic profile and geographic location of the Australian population. Shortages of dentists persist across many IRSD deciles in regional and rural areas. Within major cities there are fewer dentists per capita in the lower socio-economic districts.

Cost savings associated with timely treatment of botulism with botulism antitoxin heptavalent product

Background

Botulism is a rare, serious, and sometimes fatal paralytic illness caused by exposure to neurotoxins produced by Clostridium botulinum bacteria. Patients with documented or suspected exposure to botulinum toxin serotypes A-G can be treated with BAT^® [Botulism Antitoxin Heptavalent (A, B, C, D, E, F, G)–(Equine)] product, which was approved in 2013 in the United States (US). Patients with botulism have demonstrated greater clinical benefit with early BAT product treatment (≤2 days from symptom onset) versus late treatment (>2 days).

Objective

Economic outcomes associated with improved clinical outcome benefits of BAT product treatment have not yet been reported. This ad hoc analysis aimed to estimate and compare costs associated with hospitalization, intensive care unit stay, and mechanical ventilation for patients with botulism administered BAT product treatment early or late.

Methods

Clinical outcomes data for early and late BAT product treatment were obtained from a patient registry conducted between October 2014 and July 2017. Total per patient mean daily costs were estimated based on information from published literature. Total population costs per group were calculated by multiplying estimated mean cost per patient by the average annual number of non-infant botulism cases in the US.

Results

Mean per patient costs were 2.5 times lower for patients treated with BAT product early versus late. On average in the US, early BAT product treatment could save greater than $3.9 million per year versus late treatment.

Conclusion

Substantial economic savings can be achieved with early BAT product treatment. The findings support the recommendation for public health authorities to ensure antitoxin treatment is readily available in sufficient quantities to manage botulism cases, including sporadic outbreaks and potential mass exposure biological attacks.

2158. Cost-Effectiveness and Budget Impact of a Point-of-Care Nucleic Acid Amplification Test for Diagnosis of Group A Streptococcal Pharyngitis in the United States

Background

Group A streptococcal (GAS) pharyngitis is common in the United States (US). Each year, approximately 12 million people seek medical care for pharyngitis, accounting for ~2% of ambulatory care visits. The gold standard method for diagnosing GAS is culture. However, because culture is time intensive, rapid antigen detection tests (RADTs), with or without culture confirmation, are commonly used. Although RADTs provide results quickly, test sensitivity has been shown to be sub-optimal, which can lead to inappropriate treatment decisions. Recently, highly sensitive point-of-care nucleic acid amplification tests (POC NAAT), such as the cobas® Liat® System, have emerged. The objective of this study was to evaluate the cost-effectiveness (CE) and budget impact (BI) of adopting POC NAAT compared with RADT+culture confirmation to diagnose GAS pharyngitis from the US third-party payer perspective.

Methods

A decision-tree economic model was developed in Microsoft Excel to quantify costs and clinical outcomes associated with POC NAAT and RADT+culture over a one-year period. All model inputs were derived from published literature and public databases. Model outputs included costs and clinical effects measured as quality-adjusted life days (QALDs) lost. One-way and probabilistic sensitivity analyses were performed to assess the impact of uncertainty on results.

Results

CE analysis showed that POC NAAT would cost $44 per patient compared with $78 with RADT+ culture. POC NAAT was associated with fewer QALDs lost relative to RADT+ culture. Therefore, POC NAAT may be considered the “dominant” strategy (i.e., lower costs and higher effectiveness). Findings were robust in sensitivity analyses. BI analysis showed that adopting POC NAAT for diagnosis of GAS could yield cost-savings of 0.3% vs. current budget over 3 years. This is due to savings associated with testing, GAS-related complications, antibiotic treatment and treatment-associated complication costs.

Conclusion

Results suggest that adopting POC NAAT to diagnose GAS would be considered cost-effective and yield cost-savings for US payers relative to RADT+culture. Access to POC NAAT would be important to optimize appropriate GAS diagnosis and treatment decisions.

Disclosures

All authors: No reported disclosures.

Cost-Effectiveness of the Use of Autologous Cell Harvesting Device Compared to Standard of Care for Treatment of Severe Burns in the United States

Introduction

When introducing a new intervention into burn care, it is important to consider both clinical and economic impacts, as the financial burden of burns in the USA is significant. This study utilizes a health economic modeling approach to estimate cost-effectiveness and burn center budget-impact for the use of the RECELL^® Autologous Cell Harvesting Device to prepare autologous skin cell suspension (ASCS) compared to standard of care (SOC) split-thickness skin graft (STSG) for the treatment of severe burn injuries requiring surgical intervention for definitive closure.

Methods

A hospital-perspective model using sequential decision trees depicts the acute burn care pathway (wound assessment, debridement/excision, temporary coverage, definitive closure) and predicts the relative differences between use of ASCS compared to SOC. Clinical inputs and ASCS impact on length of stay (LOS) were derived from clinical trials and real-world use data, American Burn Association National Burn Repository database analyses, and burn surgeon interviews. Hospital resource use and unit costs were derived from three US burn centers. A budget impact calculation leverages Monte Carlo simulation to estimate the overall impact to a burn center.

Results

ASCS treatment is cost-saving or cost-neutral (< 2% difference) and results in lower LOS compared to SOC across expected patient profiles and scenarios. In aggregate, ASCS treatment saves a burn center 14–17.3% annually. Results are sensitive to, but remain robust across, changing assumptions for relative impact of ASCS use on LOS, procedure time, and number of procedures.

Conclusions

Use of ASCS compared to SOC reduces hospital costs and LOS of severe burns in the USA.

Funding

AVITA Medical.

Electronic supplementary material

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Ertugliflozin Compared to Other Anti-hyperglycemic Agents as Monotherapy and Add-on Therapy in Type 2 Diabetes: A Systematic Literature Review and Network Meta-Analysis

INTRODUCTION

Ertugliflozin is a new sodium-glucose co-transporter-2 inhibitor (SGLT2i) for the treatment of type 2 diabetes mellitus. As there are no head-to-head trials comparing the efficacy of SGLT2is, the primary objective of this analysis was to indirectly compare ertugliflozin to other SGLT2i in patient populations with inadequately controlled glycated hemoglobin (HbA1c > 7.0%) and previously treated with either diet/exercise, metformin alone or metformin plus a dipeptidyl peptidase-4 inhibitor (DPP4i).

METHODS

A systematic literature review (SLR) identified randomized controlled trials (RCTs) reporting outcomes at 24-26 weeks of treatment. Comparators to ertugliflozin were the SGLT2is canagliflozin, dapagliflozin and empagliflozin, with non-SGLT2i comparators also evaluated third-line [insulin and glucagon-like peptide-1 receptor agonists (GLP-1 RAs)]. Outcomes were change from baseline in HbA1c, weight and systolic blood pressure (SBP) as well as HbA1c < 7% and key safety events. Bayesian network meta-analysis was used to synthesize evidence. Results are presented as the median of the mean difference (MD) or as odds ratios with 95% credible intervals (CrI).

RESULTS

In patients uncontrolled on diet/exercise, the efficacy of ertugliflozin 5 mg monotherapy was not significantly different from that of other low-dose SGLT2is in terms of HbA1c reduction, while ertugliflozin 15 mg was more effective than dapagliflozin 10 mg (MD - 0.36%, CrI - 0.65, - 0.08) and empagliflozin 25 mg (MD - 0.31%, CrI - 0.58, - 0.04). As add-on therapy to metformin, ertugliflozin 5 mg was more effective in lowering HbA1c than dapagliflozin 5 mg (MD - 0.22%, CrI - 0.42, - 0.02), and ertugliflozin 15 mg was more effective than dapagliflozin 10 mg (MD - 0.26%, CrI - 0.46, - 0.06) and empagliflozin 25 mg (MD - 0.23%, CrI - 0.44, - 0.03). Among patients uncontrolled on combination therapy metformin plus a DPP4i, no relevant RCTs with insulin were identified from the SLR. One study with a GLP-1 RA was included in a sensitivity analysis due to limited data. There were no differences between ertugliflozin 5 or 15 mg and other SGLT2is, with the exception of dapagliflozin 10 mg, which was significantly less effective when added to sitagliptin and metformin. Overall, there were no other significant differences for remaining efficacy and safety outcomes except for a lower SBP for canagliflozin 300 mg compared to ertugliflozin 15 mg in the diet/exercise population.

CONCLUSIONS

Indirect comparisons for HbA1c reduction found that ertugliflozin 5 mg was more effective than dapagliflozin 5 mg when added to metformin monotherapy, whereas ertugliflozin 15 mg was more effective than dapagliflozin 10 mg and empagliflozin 25 mg when added to diet/exercise and to metformin monotherapy. The HbA1c reduction associated with ertugliflozin was no different than that associated with canagliflozin across all populations.

FUNDING

Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA, and Pfizer Inc., New York, NY, USA.

The distribution of allied dental practitioners in australia: socio-economics and rurality as a driver of better health service accessibility

OBJECTIVES

Analysis of the distribution of allied dental practitioners relative to the socio-economic profile of the population, to develop a baseline of employment demographics at a time of proposed deregulation of practicing restrictions.

METHODS

A database of allied dental practitioners (ADP - oral health therapists, dental therapists and dental hygienists) was compiled from the public access register of the Australian Health Practitioner Regulation Agency. The principal practice locations limited to suburb and postcode were geocoded by latitude and longitude and superimposed on a map of the Australian landmass using QGIS software. Using Australian Bureau of Statistics data, the number of ADPs for each Statistical Area 2 (SA2) was counted and apportioned according to proportion of the population within each SA2 for each quintile of the Index of Relative Socio-economic Disadvantage (IRSD). The results were reported according to oral health therapists, dental therapists and dental hygienists per 100 000 population for each IRSD quintile, by state and territory, and the Australian Regional Index for Areas (ARIA+).

RESULTS

The ADP to population ratio was not consistent for each professional class between states and territories, IRSD quintiles and (ARIA+) regional areas. Across major cities, South Australia was the state with the highest ratio of oral health therapists (10.6-12.9) and dental hygienists (14.6-24.5) for all IRSD quintiles. Western Australia had the highest ratio of dental therapists (9.3-16.0), CONCLUSION: There is no consistent pattern of distribution of ADPs relative to the socio-economic profile of the population across states and territories, and regional (ARIA+) areas of Australia.

The Distribution of Dental Health Specialist Locations in Sri Lanka

AIM

To investigate the distribution of dental health specialist locations staffed by Oral and Maxillo-Facial Surgeons (OMF), Restorative dentists, and Orthodontists in Sri Lanka in relation to population distribution and socio-economic status.

METHODS

Specialist dental locations were mapped using GIS (Geographic Information System) and overlayed with census population data and socio-economic quintiles.

RESULTS

Overall, there was an uneven geographic distribution of the total 55 specialist dental locations and 74 attributed specialist work force within the country. Access to specialist care is remarkably high in Western and Central provinces, compared to the Northern, Eastern and North Central provinces. When the geographic distribution was compared to population socio-economics, it was found that in Sri Lanka only 22.3%, 44.4%, and 25.4% of the most disadvantaged lived within 20 kms from an Orthodontic, OMF and Restorative clinic respectively, compared to 66.3%, 82.8% and 44.7% of the least disadvantaged.

CONCLUSION

The findings of this study can contribute to the decision-making process when determining future locations of dental specialist clinics and identifying subgroups in the population who are geographically and socio-economically isolated from accessing care.

Cost-effectiveness analysis of FOLFOX4 and sorafenib for the treatment of advanced hepatocellular carcinoma in China

Objectives

Hepatocellular carcinoma (HCC) is a leading cause of cancer-related deaths globally. In China, sorafenib and oxaliplatin plus infusional-fluorouracil/leucovorin (FOLFOX4) are approved for the systemic treatment of advanced HCC. This study compared the cost-effectiveness of these therapies from a healthcare system perspective and a patient perspectives.

Methods

A Markov model was constructed using overall and progression-free survival rates and adverse event (AE) rate from two randomized controlled studies of advanced HCC patients from Asia: EACH for FOLFOX4 and ORIENTAL for sorafenib. The patients in the Markov model were followed until death, the length of each Markov cycle was 1 month, and the survival was adjusted for quality-adjusted life years (QALYs). Direct medical costs included costs of therapies, AE treatment, general ward and tests. Costs were derived from published sources, interviews with oncologists and hospital data from China. One-way and probabilistic sensitivity analyses (PSA) were performed to test the robustness of the results.

Results

From the healthcare system perspective, FOLFOX4 dominated sorafenib with lower therapy costs (FOLFOX4: US$ 6972; sorafenib: US$ 12,289), lower direct medical costs (FOLFOX4: US$ 8428; sorafenib: US$ 12,798), and higher QALYs (FOLFOX4: 0.42; sorafenib: 0.38) per patient. This result was robust according to comprehensive one-way sensitivity analyses. According to the PSA, at the cost-effectiveness threshold for China (3 × GDP, US$ 22,073), FOLFOX4 should be chosen in 63.9% of simulations. From the patient perspective, FOLFOX4 also dominated sorafenib.

Conclusions

The study results indicate that FOLFOX4 dominates sorafenib because it appears to provide higher effectiveness with significantly lower costs in treating Chinese advanced HCC patients.

Validity and reliability of remote dental screening by different oral health professionals using a store-and-forward telehealth model

Objective This study was conducted to evaluate the validity and reliability of intraoral photographic assessments by different members of a dental team as a means for dental screening in children.Methods The intraoral photographic records of 126 children (2 to 18 years old) were obtained from routine clinical records taken before dental treatment. Intraoral photographs were obtained using a DSLR camera and then uploaded to a cloud-based server using store-and-forward telehealth technology. Images were reviewed by an expert panel to formulate a benchmark screening baseline, to which the screeners' data were compared. The photographic assessments conducted by a mid-level dental practitioner (MLDP) and dentist, were compared to the benchmark expert panel assessment.Results The screeners' assessments by means of intraoral photography, when compared to the expert panel assessment had a sensitivity value of 82-89% and specificity value of 97%. The inter-examiner agreement between the expert panel assessment and photographic method (assessed by a dentist and MLDP), was almost perfect, with a kappa score ranging from 0.82 to 0.88. The mean DFT/dft score for the children as determined by the expert panel's review and photographic assessment ranging from 5.41 to 5.79, with mean scores between the two assessment methods not significantly different (P = 0.746).Conclusion Our results suggested that oral health professionals (other than dentists) have the potential to screen for caries from intraoral photographs with the same diagnostic accuracy and reliability as dentists. This strategy has implications for supporting the use of MLDPs such as dental therapists or hygienists to screen for oral disease using telehealth.

Cost-effectiveness of de-escalation from micafungin versus escalation from fluconazole for invasive candidiasis in China

AIMS

Guidelines on treating invasive candidiasis recommend initial treatment with a broad-spectrum echinocandin (e.g. micafungin), then switching to fluconazole if isolates prove sensitive (de-escalation strategy). This study aimed to evaluate the cost-effectiveness of de-escalation from micafungin vs escalation from fluconazole from a Chinese public payers perspective.

MATERIALS AND METHODS

Cost-effectiveness was estimated using a decision analytic model, in which patients begin treatment with fluconazole 400 mg/day (escalation) or micafungin 100 mg/day (de-escalation). From Day 3, when susceptibility results are available, patients are treated with either fluconazole (if isolates are fluconazole-sensitive/dose-dependent) or micafungin (if isolates are resistant). The total duration of (appropriate) treatment is 14 days. Model inputs are early (Day 3) and end-of-treatment mortality rates, treatment success rates, and health resource utilization. Model outputs are costs of health resource utilization over 42 days, incremental cost per life-year, and incremental cost per quality-adjusted life-year (QALY) over a lifetime horizon.

RESULTS

In the base-case analysis, the de-escalation strategy was associated with longer survival and higher treatment success rates compared with escalation, at a lower overall cost (-¥1,154; -175 United States Dollars). Life-years and QALYs were also better with de-escalation. Thus, this strategy dominated the escalation strategy for all outcomes. In a probabilistic sensitivity analysis, 99% of 10,000 simulations were below the very cost-effective threshold (1 × gross domestic product).

LIMITATIONS

The main limitation of the study was the lack of real-world input data for clinical outcomes on treatment with micafungin in China; data from other countries were included in the model.

CONCLUSION

A de-escalation strategy is cost-saving from the Chinese public health payer perspective compared with escalation. It improves outcomes and reduces costs to the health system by reducing hospitalization, due to an increase in the proportion of patients receiving appropriate treatment.

Impact of ledipasvir/sofosbuvir on the work productivity of genotype 1 chronic hepatitis C patients in Asia

Chronic, untreated hepatitis C virus (HCV) infection is associated with a poor clinical prognosis and a detrimental impact on patients' lives, including on work productivity. To estimate the value of productivity losses due to genotype 1 (GT1) HCV infection in Hong Kong, Singapore, South Korea and Taiwan and to estimate the potential productivity gains associated with treating patients with ledipasvir/sofosbuvir (LDV/SOF) therapy, an economic model was developed with a time horizon of 1 year. Hepatitis C virus patients entered the model at 12 weeks post-treatment, having achieved or not achieved sustained virological response (SVR). Absenteeism and presenteeism rates were taken from a pooled analysis of data from the ION 1-3 studies. These rates were converted into hours of lost productivity, multiplied by the average wage and applied to the total employed, adult GT1 population in each country. Results were compared assuming no treatment, and assuming all patients were treated with LDV/SOF. Total productivity losses due to untreated HCV were: $11.3 million, $17.1 m, $146.0 m and $349.1 m in Hong Kong, Singapore, South Korea and Taiwan. LDV/SOF treatment resulted in economic gains of $4.5 m, $6.8 m, $58.7 m and $138 m, respectively. These gains were due to reduced presenteeism. The results were sensitive to changes in the prevalence of HCV and the average wage. In conclusion, productivity losses due to untreated HCV infection represent a substantial economic burden. By instituting universal HCV treatment with LDV/SOF (or other therapies with high SVR rates), productivity gains can be achieved.

Is there a consensus on antibiotic usage for dental implant placement in healthy patients?

This systematic review aimed to determine whether there is consensus for antibiotic prescription in healthy patients undergoing implant placement. A search of PubMed, Embase and Medline databases was conducted in January 2016 to find published journal articles on the use of antibiotics in implant placement, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The inclusion criteria were prospective human clinical trials investigating antibiotic usage during implant placement. Fifteen studies were deemed suitable. In 13 studies, no statistical difference was found between antibiotic use and the incidence of prosthetic failure, implant failure and early postoperative infections. These were rated as having low to high risk bias. Contrary results were reported in two studies, both of which were rated as having a high potential for bias. In conclusion, antibiotic use in healthy patients for the prophylaxis of surgical infection associated with dental implant placement does not appear to improve clinical outcomes. Practitioners should apply principles of antimicrobial stewardship and not use antibiotics as a routine measure in healthy patients.

Public health intervention over four decades for the children in the Australian Capital Territory: Have we reached the point of diminishing returns?

BACKGROUND

Most of the developed world has seen some substantial improvements in the dental health of children over the past four decades owing to advances in service access, fluoride exposure, socio-economic development and improved diets, with the DMFT score of 12 year-olds dropping from well over 10 down to around one.

AIM

To examine the question of advancing dental health for children even further using the same set of tools as we have to date by asking the question: Have we come to a point of diminishing returns? The study examines the long-term, near optimum settings of the known public dental health variables in the Australian Capital Territory.

RESULTS

Despite having the most ideal and persistent dental health optimised situation, there remains underlying dental caries at a severity level of just below 1 DMFT (12 year olds), and over the last decade the rate of diminishing incidence and prevalence of decay has slowed and arguably stopped.

CONCLUSION

This suggests that rather than toiling to eliminate dental decay completely, the focus might usefully be reoriented towards those small known pockets of society with persistent higher levels of disease and looking for new ways to address these difficult clusters, while simultaneously advancing the understanding that a small residual level of decay will always exist in society.

Evaluation of a semi-automated software program for the identification of vertebral fractures in children

AIM

To assess observer reliability and diagnostic accuracy in children, of a semi-automated six-point technique developed for vertebral fracture (VF) diagnosis in adults, which records percentage loss of vertebral body height.

MATERIALS AND METHODS

Using a semi-automated software program, five observers independently assessed T4 to L4 from the lateral spine radiographs of 137 children and adolescents for VF. A previous consensus read by three paediatric radiologists using a simplified algorithm-based qualitative technique (i.e., no software involved) served as the reference standard.

RESULTS

Of a total of 1,781 vertebrae, 1,187 (67%) were adequately visualised according to three or more observers. Interobserver agreement in vertebral readability for each vertebral level for five observers ranged from 0.05 to 0.47 (95% CI: -0.19, 0.76). Intra-observer agreement using the intraclass correlation coefficient (ICC) ranged from 0.25 to 0.61. The overall sensitivity and specificity were 18% (95% CI: 14-22) and 97% (95% CI: 97-98), respectively.

CONCLUSION

In contrast to adults, the six-point technique assessing anterior, middle, and posterior vertebral height ratios is neither satisfactorily reliable nor sensitive for VF diagnosis in children. Training of the software on paediatric images is required in order to develop a paediatric standard that incorporates not only specific vertebral body height ratios but also the age-related physiological changes in vertebral shape that occur throughout childhood.

Cost-effectiveness of EOB-MRI for Hepatocellular Carcinoma in Japan

PURPOSE

The objective of the study was to evaluate the cost-effectiveness of gadoxetic acid-enhanced magnetic resonance imaging (EOB-MRI) in the diagnosis and treatment of hepatocellular carcinoma (HCC) in Japan compared with extracellular contrast media-enhanced MRI (ECCM-MRI) and contrast media-enhanced computed tomography (CE-CT) scanning.

METHODS

A 6-stage Markov model was developed to estimate lifetime direct costs and clinical outcomes associated with EOB-MRI. Diagnostic sensitivity and specificity, along with clinical data on HCC survival, recurrence, treatment patterns, costs, and health state utility values, were derived from predominantly Japanese publications. Parameters unavailable from publications were estimated in a Delphi panel of Japanese clinical experts who also confirmed the structure and overall approach of the model. Sensitivity analyses, including one-way, probabilistic, and scenario analyses, were conducted to account for uncertainty in the results.

FINDINGS

Over a lifetime horizon, EOB-MRI was associated with lower direct costs (¥2,174,869) and generated a greater number of quality-adjusted life years (QALYs) (9.502) than either ECCM-MRI (¥2,365,421, 9.303 QALYs) or CE-CT (¥2,482,608, 9.215 QALYs). EOB-MRI was superior to the other diagnostic strategies considered, and this finding was robust over sensitivity and scenario analyses. A majority of the direct costs associated with HCC in Japan were found to be costs of treatment. The model results revealed the superior cost-effectiveness of the EOB-MRI diagnostic strategy compared with ECCM-MRI and CE-CT.

IMPLICATIONS

EOB-MRI could be the first-choice imaging modality for medical care of HCC among patients with hepatitis or liver cirrhosis in Japan. Widespread implementation of EOB-MRI could reduce health care expenditures, particularly downstream treatment costs, associated with HCC.

Reliability and repeatability of pulp volume reconstruction through three different volume calculations

OBJECTIVE

To test the variability of the volume measurements when different segmentation methods are applied in pulp volume reconstruction.

MATERIALS AND METHODS

Osirix® and ITK-SNAP software were used. Different segmentation methods (Part A) and volume approaches (Part B) were tested in a sample of 21 dental CBCT's from upper canines. Different combinations of the data set were also tested on one lower molar and one upper canine (Part C) to determine the variability of the results when automatic segmentation is performed.

RESULTS

Although the obtained results show correlation among them(r > 0.75), there is no evidence that these methods are sensitive enough to detect small volume changes in structures such as the dental pulp canal (Part A and Part B). Automatic segmentation is highly susceptible to be affected by small variations in the setting parameters (Part C).

CONCLUSIONS

Although the volumetric reconstruction and pulp/tooth volume ratio has not shown better results than methods based on dental radiographs, it is worth to persevere with the research in this area with new development in imaging techniques.

Identifying and prioritising areas of child dental service need: a GIS-based approach

AIM

To identify and prioritise areas of high need for dental services among the child population in metropolitan Western Australia.

DESIGN

All children hospitalised due to an oral-condition from 2000 to 2009, at metropolitan areas of Perth were included in the analysis of a 10-year data set. QGIS tools mapped the residential location of each child and socioeconomic data in relation to existing services (School Dental Service clinics).

RESULTS

The tables and maps provide a clear indication of specific geographical areas, where no services are located, but where high hospital-admission rates are occurring, especially among school-age children. The least-disadvantaged areas and areas of high rates of school-age child hospital-admissions were more likely to be within 2km of the clinics than not. More of high-risk-areas (socio-economically deprived areas combined with high oral-related hospital admissions rates), were found within 2km of the clinics than elsewhere.

CONCLUSION

The application of GIS methodology has identified a community's current service access needs, and assisted evidence based decision making for planning and implementing changes to increase access based on risk.

A retrospective audit of population service access trends for cleft lip and cleft palate patients

Population prevalence of orofacial clefts (OFCs) is well documented but the service utilisation patterns of these patients have received limited consideration.

OBJECTIVE

To analyse 10-year trends in the utilisation of subsidised OFC related services in Australia.

DESIGN

Retrospective audit of service utilisation and claims datasets.

METHODS

Using state-wide hospital admission data, all persons treated for Cleft Palate Only (CPO) and Cleft Lip Only (CLO) as their primary diagnosis from 1999 to 2009 in Western Australia were included in the data frameset. Additionally, National Medicare out-of-hospital claims from 2003 to 2013 were added to the data frameset. The socioeconomic status and accessibility to services were analysed as effectors of service-mix such as age group, gender and geographic location.

RESULTS

Of 721 in-hospital care episodes in Western Australia, 69% had CPO and 31% CLO as their principal diagnosis. Hospitalisations occurred from 0-69 years of age, but three quarters of all episodes occurred from 0-4 years of age (averaging one to two episodes per child). Whilst total hospitalisations were about four times higher for patients resident in high access areas, adjustment for population found the poorest 20% of the population having substantially lower hospital admission rates than the rest of the population. In Australia, claims for out-of-hospital cleft-related services varied between States. The overall pattern of out-of-hospital Medicare claims nationwide showed orthodontic services having the highest number of claims, followed by prosthodontic then oral surgical services.

CONCLUSION

These data provide a picture of diverse service utilisation and leads to some interesting conclusions about geographic and economic access as well as cost-shifts between State and Commonwealth.

The role of a bus network in access to primary health care in Metropolitan Auckland, New Zealand

Background: This study examined the spatial accessibility of the population of metropolitan Auckland, New Zealand to the bus network, to connect them to primary health providers, in this case doctors (GP) and dentists. Analysis of accessibility by ethnic identity and socio-economic status were also carried out, because of existing health inequalities along these dimensions. The underlying hypothesis was that most people would live within easy reach of primary health providers, or easy bus transport to such providers.

METHODS

An integrated geographic model of bus transport routes and stops, with population and primary health providers (medical. and dental practices) was developed and analysed.

RESULTS

Although the network of buses in metropolitan Auckland is substantial and robust it was evident that many people live more than 150 metres from a stop.

CONCLUSION

Improving the access to bus stops, particularly in areas of high primary health care need (doctors and dentists), would certainly be an opportunity to enhance spatial access in a growing metropolitan area.

Cost-Effectiveness Analysis of Qsymia for Weight Loss

BACKGROUND

Phase 3 clinical trial results reveal that Qsymia is a clinically effective long-term treatment for obesity, but whether this treatment is cost-effective compared to a diet and lifestyle intervention has yet to be explored.

OBJECTIVE

To quantify the incremental cost-effectiveness of Qsymia (phentermine and topiramate extended-release) for health-related quality of life improvements.

STUDY DESIGN AND METHODS

Estimates are based on cost and quality of life outcomes from a 56-week, multicenter, placebo-controlled, phase 3 clinical trial undertaken in 93 health centers in the US. Participants were overweight and obese adults (aged 18-70 years) with a body-mass index of 27-45 kg/m(2) and two or more comorbidities (hypertension, dyslipidemia, diabetes or pre-diabetes or abdominal obesity). The intervention was diet and lifestyle advice plus the recommended dose of Qsymia (phentermine 7.5 mg plus topiramate 46.0 mg) vs. control, which included diet and lifestyle advice plus placebo. The study was from the payer perspective. Costs included the prescription cost, medication cost offsets and physician appointment costs. Effectiveness was measured in terms of quality-adjusted life years gained (QALYs). The main outcome measure was incremental cost per QALY gained of the intervention relative to control.

RESULTS

Our base-case model, in which participants take Qsymia for 1 year with benefits linearly decaying over the subsequent 2 years, generates an incremental cost-effectiveness ratio (ICER) of $48,340 per QALY gained. Using the base-case assumptions, probabilistic sensitivity analyses reveal that the ICER is below $50,000 per QALY in 54 % of simulations. However, results are highly dependent on the extent to which benefits are maintained post medication cessation. If benefits persist for only 1 year post cessation, the ICER increases to $74,480.

CONCLUSION

Although base-case results suggest that Qsymia is cost-effective, this result hinges on the time on Qsymia and the extent to which benefits are maintained post medication cessation. This should be an area of future research.

Potentially preventable hospital separations related to oral health: a 10-year analysis

BACKGROUND

The aims of this study were to assess the rates of hospitalizations for potentially preventable dental conditions over a 10-year period in Western Australia; to analyse trends over 10 years in rate changes of hopitalizations; and to analyse the mix of preventable dental conditions by age group and Aboriginal status.

METHODS

The principal diagnosis, as classified by the International Classification of Disease (ICD-10AM), was used to select hospitalization data for all patients who were discharged from hospital in Western Australia for the financial years 1999-2000 to 2008-2009, for a potentially preventable oral health condition.

RESULTS

Over a 10-year period more than 65 000 people were hospitalized. Population rates of hospitalization increased significantly over the period for both Aboriginal and non-Aboriginal population groups. Admission rates were higher for Aboriginal people. Children under 14 were more likely to be admitted; the most common condition that required hospitalization was dental caries, and the highest rates of hospitalization were for those from the most socio-economically disadvantaged areas.

CONCLUSIONS

These hospitalizations remain a considerable and increasing financial burden on health budgets. An increase in efforts is necessary to curb escalating government health expenditure by reducing avoidable and preventable oral health related hospitalizations.

Building a stronger child dental health system in Australia: statistical sampling masks the burden of dental disease distribution in Australian children

INTRODUCTION

In Australia, over the past 30 years, the prevalence of dental decay in children has reduced significantly, where today 60-70% of all 12-year-olds are caries free, and only 10% of children have more than two decayed teeth. However, many studies continue to report a small but significant subset of children suffering severe levels of decay.

METHODS

The present study applies Monte Carlo simulation to examine, at the national level, 12-year-old decayed, missing or filled teeth and shed light on both the statistical limitation of Australia's reporting to date as well as the problem of targeting high-risk children.

RESULTS

A simulation for 273 000 Australian 12-year-old children found that moving from different levels of geographic clustering produced different statistical influences that drive different conclusions. At the high scale (ie state level) the gross averaging of the non-normally distributed disease burden masks the small subset of disease bearing children. At the much higher acuity of analysis (ie local government area) the risk of low numbers in the sample becomes a significant issue.

CONCLUSIONS

The results clearly highlight the importance of care when examining the existing data, and, second, opportunities for far greater levels of targeting of services to children in need. The sustainability (and fairness) of universal coverage systems needs to be examined to ensure they remain highly targeted at disease burden, and not just focused on the children that are easy to reach (and suffer the least disease).

Meta- and cost-effectiveness analysis of commercial weight loss strategies

OBJECTIVE

To estimate the incremental cost-effectiveness of clinically proven nonsurgical commercial weight loss strategies for those with BMIs between 25 and 40.

METHODS

We performed a systematic literature review to identify randomized controlled trials of commercially available weight loss studies of at least 1 year in duration. Using the results of these trials and publicly available cost data, we quantified the incremental cost per kilogram of weight loss and per quality adjusted life year (QALY) gained. We then use probabilistic sensitivity analyses to quantify uncertainty in our results.

RESULTS

Based on the literature review, two lifestyle programs (Weight Watchers and Vtrim), one meal replacement program (Jenny Craig), and three pharmaceutical products (Qsymia, Lorcaserin, and Orlistat) were included in the analysis. Average cost per kilogram of weight lost ranged from $155 (95% CI: $110-$218) for Weight Watchers to $546 (95% CI: $390-$736) for Orlistat. The incremental cost per QALY gained for Weight Watchers and Qsymia was $34,630 and $54,130, respectively. All other interventions were prohibitively expensive or inferior in that weight loss could be achieved at a lower cost through one or a combination of the other strategies.

CONCLUSIONS

Results suggest that, in the absence of other considerations and at current market prices, Weight Watchers and Qsymia represent the two most cost-effective strategies for nonsurgical weight loss.

A comparison of live counseling with a web-based lifestyle and medication intervention to reduce coronary heart disease risk: a randomized clinical trial

IMPORTANCE

Most primary care clinicians lack the skills and resources to offer effective lifestyle and medication (L&M) counseling to reduce coronary heart disease (CHD) risk. Thus, effective and feasible CHD prevention programs are needed for typical practice settings.

OBJECTIVE

To assess the effectiveness, acceptability, and cost-effectiveness of a combined L&M intervention to reduce CHD risk offered in counselor-delivered and web-based formats.

DESIGN, SETTING, AND PARTICIPANTS

A comparative effectiveness trial in 5 diverse family medicine practices in North Carolina. Participants were established patients, aged 35 to 79 years, with no known cardiovascular disease, and at moderate to high risk for CHD (10-year Framingham Risk Score [FRS], ≥10%).

INTERVENTIONS

Participants were randomized to counselor-delivered or web-based format, each including 4 intensive and 3 maintenance sessions. After randomization, both formats used a web-based decision aid showing potential CHD risk reduction associated with L&M risk-reducing strategies. Participants chose the risk-reducing strategies they wished to follow.

MAIN OUTCOMES AND MEASURES

The primary outcome was within-group change in FRS at 4-month follow-up. Other measures included standardized assessments of blood pressure, blood lipid levels, lifestyle behaviors, and medication adherence. Acceptability and cost-effectiveness were also assessed. Outcomes were assessed at 4 and 12 months.

RESULTS

Of 2274 screened patients, 385 were randomized (192 counselor; 193 web): mean age, 62 years; 24% African American; and mean FRS, 16.9%. Follow-up at 4 and 12 months included 91% and 87% of the randomized participants, respectively. There was a sustained reduction in FRS at both 4 months (primary outcome) and 12 months for both counselor-based (-2.3% [95% CI, -3.0% to -1.6%] and -1.9% [95% CI, -2.8% to -1.1%], respectively) and web-based groups (-1.5% [95% CI, -2.2% to -0.9%] and -1.7% [95% CI, -2.6% to -0.8%] respectively). At 4 months, the adjusted difference in FRS between groups was -1.0% (95% CI, -1.8% to -0.1%) (P = .03), and at 12 months, it was -0.6% (95% CI, -1.7% to 0.5%) (P = .30). The 12-month costs from the payer perspective were $207 and $110 per person for the counselor- and web-based interventions, respectively.

CONCLUSIONS AND RELEVANCE

Both intervention formats reduced CHD risk through 12-month follow-up. The web format was less expensive.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01245686.

Predicting geographically distributed adult dental decay in the greater Auckland region of New Zealand

OBJECTIVE

To model the geographic distribution of current (and treated) dental decay on a high-resolution geographic basis for the Auckland region of New Zealand.

BASIC RESEARCH DESIGN

The application of matrix-based mathematics to modelling adult dental disease-based on known population risk profiles to provide a detailed map of the dental caries distribution for the greater Auckland region.

RESULTS

Of the 29 million teeth in adults in the region some 1.2 million (4%) are suffering decay whilst 7.2 million (25%) have previously suffered decay and are now restored.

CONCLUSIONS

The model provides a high-resolution picture of where the disease burden lies geographically and presents to health planners a method for developing future service plans.