Payment methods may influence behaviour of primary care dentists

Data sources: The Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Embase, EconLit the NHS Economic Evaluation Database (EED) and the Health Economic Evaluations Database (HEED). Study selection: Randomised controlled trials (RCTs), non-randomised controlled clinical trials (NRCTs), controlled before-after (CBA) studies and interrupted time series (ITS) studies were considered. Study selection was undertaken independently by three reviewers. Fee-for-service payments, fixed salary payments, capitation payments of combinations thereof included. Data extraction and synthesis: Standard Cochrane methodological procedures were followed. Results: Two cluster-RCTs, with data from 503 dental practices, representing 821 dentists and 4771 patients, met the selection criteria. The risk of bias for the two studies was considered to be high and the overall quality of evidence for the outcomes was low/very low for all outcomes, as assessed using the GRADE approach.One study conducted in the four most deprived areas of Scotland used a factorial design to investigate the impact of fee-for-service and an educational intervention on the placement of fissure sealants. The authors reported a statistically significant increase in clinical activity in the arm that was incentivised with a fee-for-service payment. Measures of health service utilisation or patient outcomes were not reported. The second study used a parallel group design undertaken over a three-year period to compare the impact of capitation payments with fee-for-service payments on primary care dentists' clinical activity. The study reported on measures of clinical activity, patient outcomes and healthcare costs. Teeth were restored at a later stage in the disease process in the capitation system and the clinicians tended to see their patients less frequently and tended to carry out fewer fillings and extractions, but also tended to give more preventive advice.There was insufficient information regarding the cost-effectiveness of the different remuneration methods. Conclusions: Financial incentives within remuneration systems may produce changes to clinical activity undertaken by primary care dentists. However, the number of included studies is limited and the quality of the evidence from the two included studies was low/very low for all outcomes. Further experimental research in this area is highly recommended given the potential impact of financial incentives on clinical activity, and particular attention should be paid to the impact this has on patient outcomes