Cost and benefits of cone beam computed tomography : for maxillary canines with eruption disturbance

I tandvården finns allt fler metoder för prevention, diagnostik och behandling. Eftersom resurserna är begränsade bör den metod väljas där nyttan uppväger kostnaden. Idag saknas dock vetenskapliga belägg gällande kostnadseffektivitet för undersökning med Cone Beam Computed Tomography (CBCT). En systematisk översikt i Studie I identifierade 160 hälsoekonomiska utvärderingar inom tandvård varav 12 gällande diagnostiska metoder. Översikten kunde inte identifiera någon kostnadsanalys på patientnivå för diagnostiska metoder. Därför konstruerades i Studie II ett ramverk för analys av kostnader förknippade med diagnostiska metoder i tandvården. Applicering av ramverket visade att CBCT och panoramaröntgen hade en signifikant högre kostnad (128,80€) jämfört med intraoral och panoramaröntgen (81,80€). I Studie III jämfördes kostnader för CBCT undersökning av patienter med olika kliniska tillstånd på kliniker i Cluj -Rumänien, Leuven -Belgien, Malmö -Sverige och Vilnius -Litauen. Klinikrelaterade kostnader varierade mellan sjukvårdssystemen vilket främst berodde på olika höga inköpskostnader för CBCT-apparaterna. I enkätundersökning i Studie IV ombads specialister i tandreglering att ta beslut om behandling gällande patienter med misstanke om eruptionsstörning av överkäkshörntanden. Majoriteten av behandlingsvalen var samma oavsett om de hade tillgång till CBCT och panorama eller till intraoral röntgen och panorama. Sammanfattningsvis kan sägas att det finns ett stort behov av hälsoekonomiska studier med god kvalitet gällande diagnostiska metoder inom tandvård. Undersökning med CBCT medför en högre kostnad än konventionella röntgenmetoder och för majoriteten av patienter med misstanke om eruptionsstörning av överkäkshörntänderna medför den ingen extra nytta avseende behandlingsbeslut.There is a continuous inflow of new imaging technologies and the question must be raised whether using the new methods provide benefits for the patients that justifies any additional costs incurred. There is a growing awareness of the need for economic evalua-tions in dentistry and further understanding in this field is a prerequisite since the diagnostic examination forms the basis for treatment planning and prognostic assessment. The use of Cone Beam Computed Tomography (CBCT) in dentistry has emerged during the last decades and it is important to investigate if it fulfils its purpose of forming a basis for treatment planning in a cost-effective way. Evidence for the costs and benefits of CBCT is still scarce. In Study I, a systematic review of the literature regarding economic evaluations for diagnostic methods in dentistry was conducted according to international guidelines. Four databases were searched and relevant publications were retrieved and assessed according to predetermined criteria for inclusion and exclusion. The methodological quality of the publications was assessed combining a protocol for diagnostic studies and a check-list for economic evaluations. Key findings: Of the 160 economic evaluations in dentistry, 12 concerned diagnostic methods. In general, the perspective of the study was not stated and the methods for costing varied. A need for improved quality of future economic evaluations was identified. In Study II, a framework for analysing costs of diagnostic methods in dentistry was constructed. The framework was tested for costing of examination using intraoral and panoramic radiography (M1) compared with CBCT and panoramic radiography (M2) regarding patients with maxillary canines with eruption dis-turbance Key findings: The framework demonstrated a feasibility of analysing relevant costs for capital, consumables, labour and patient-related cost. Examination with M2 was associated with a significantly higher cost of 128.80€ compared with that of M1 81.80€ resulting in an incremental cost for M2 of 46.58€. In Study III the costs of CBCT-examinations were analysed comparing four different clinical conditions in four different settings in Leuven –Belgium, Cluj –Romania, Malmö –Sweden and Vilnius -Lithuania. Key findings: The estimates for clinic-related costs varied among the health care systems, being highest in Malmö and lowest in Leuven. This variation was mainly due to different purchase costs for the CBCT equipment (range 148 000–227 000€). The variation in examination fees (range 0–102.02€) was the principle reason to the differences in patient-related costs. Costing of a dental radiographic method cannot be generalized from one health care system to another, without considering their specific circumstances. In Study IV a web-based survey was constructed in order to measure the proportion of orthodontists’ treatment decision that were different when comparing M2 with M1 and to analyse the costs of producing different treatment plans, regarding patients with maxillary canines with eruption disturbance. The orthodontists were randomly assigned to denote treatment decisions for four patient cases presented with; M1 or M2 at two occasions for the same patient case. Key-findings: Twenty-four percent of the treatment decisions were different when the orthodontists had access to M2 instead of M1. The total diagnostic cost per examination was 99.83€ using M1 and 134.37 using M2, resulting in an incremental cost per examination of 34.54€ for M2. This can be expressed in terms of an incremental cost-effectiveness ratio (ICER) which is a measure of the average additional cost per treatment decision that is different as a result of using CBCT imaging i.e. 143.92€