1. International Health Policy Program -Thailand Cost-utility of dental implant placement to support lower complete denture in Thailand Warisa Panichkriangkrai 1 Sirinart Tongsiri 2 Jongkol Lertiendumrong 1 Kumaree Pachanee 1 Chitpranee Vasavid 1 Phusit Prakongsai 1 1 International Health Policy Program (IHPP) – Thailand 2 Faculty of Medicine, Mahasarakham University The First Annual Conference of HTAsiaLink Grand Pacific Sovereign Hotel, Petchaburi,Thailand May 14 ‐ 16, 2012

2. International Health Policy Program -Thailand Background information – Demand for complete denture and dental implant placement in Thailand Methodologies Research findings Discussion Policy recommendations 2 Outline of presentation

3. International Health Policy Program -Thailand 3 “Complete dentures" are prosthetic devices constructed to replace missing all teeth in dental arch, and which are supported by surrounding soft and hard tissues of the oral cavity. However, when teeth are absent, the bone, especially lower Mandible, slowly desorbs. This desorption can cause problems in terms of both function and esthetics and can lead to the instability of denture. Those who do wear dentures can decrease the amount of bone loss by retaining dental implant in the form of over denture abutments. Complete denture Dental implant Background (1)

4. International Health Policy Program -Thailand  National dental health survey in 2006-2007 shows that more than 1,100,000 of Thais have already worn lower complete denture,  Almost 100,000 patients have problems with their denture such as pain, instability of denture and discomfort,  The dental implant placement can evidently improve patients’ quality of life, however the CE of this treatment using ICER has never been explored in Thailand,  The dental implant has not been included into the UHC benefit package yet. 4 Background (2)

5. International Health Policy Program -Thailand 5 Choices of treatments for conventional complete denture and dental implant Source: Data from the Royal Dental Implant Project, Institute of Dentistry, 2010 92,509 cases 1,156,360 cases 22,202 cases

6. International Health Policy Program -Thailand 6 Methods (1)  Comprehensive literature reviews and interviews key stakeholders,  Employed ICER to estimate the costs per QALYs gained between having and not having dental implant,  Costs of treatment included direct medical costs, indirect costs, cost of dental implantation, and capacity building costs,  Quality-adjusted life years or the outcome of treatment, calculated from degree of quality of life and life expectancy at specified age or age of patients receiving dental implants,  Uncertainty analysis was applied and average value was used to calculate ICER. The comparator of this study was no treatment which means patients continue wearing uncomfortable denture.

7. International Health Policy Program -Thailand 7 Target population Those who wear lower complete denture Comparator Lower complete denture wearers who are suffering from denture wearing problems, and haven’t got any treatment Timeline Dental implants can function well for the rest of patients’ life Methods (2)

8. International Health Policy Program -Thailand Research findings

9. 9 Costs of dental implant placement Cost (Baht) Direct medical costs Medical services33,600 Dental implant6,420 Preparation 840 Indirect cost1,356 total cost 42,116 Table 2: Estimates of budget impact in 5 year Table 1: Cost of dental implant placement

10. International Health Policy Program -Thailand - The sample of 75 cases comprised mostly women (70.7%) aged between 18-73 yrs, with the average age of 41.7 yrs, - Using decision tree from choices of treatments, highest level of QOL in term of satisfaction (score 0-1) for those samples : Wearing complete denture without dental implant (0.829), Success in wearing implant-supported dentures (0.771), Having contraindication for dental implant (0.53), and Failure in dental implant (0.459) 10 Quality of life (QOL) improvements

11. International Health Policy Program -Thailand 11 Incremental cost-effectiveness ratio (ICER) Starting age (year)4560 Difference in costs (Baht & US dollars) 40,504 Baht (1,306 USD) 40,504 Baht (1,306 USD) Difference in outcome (QALYs) 12.227.87 ICER (per QALY) 3,314 Baht (106 USD) 5,147 Baht (166 USD) Note: 1USD = 31 Baht

12. International Health Policy Program -Thailand  Dental implant placement is cost-effective and has low budget impact, comparing with standard criteria of National Health Security Office (NHSO)  Any treatment with ICER lower than 1 GDP per cap per QALY would be considered to be cost-effective, The tool to measure QOL of patients receiving complete denture and dental implant is very limited, and this study had limitations in sampling bias, The UCBP subcommittee decided not to include this treatment into the UHC benefit package due to the shortage of dentists and a large share of elderly unable to access complete denture, Economic evaluation is not only the single criteria for making decisions on including any health interventions into the UHC benefit package. 12 Discussion and Conclusions

13. International Health Policy Program -Thailand  There are a number of priorities for scaling up health system capacity for dental care in Thailand,  number of trained dentists,  access to complete denture of the elderly, and  Appropriate financing system for improving access to dental care in Thailand,  The most important priority is to increase access of elderly patients to get complete dentures which is the basic treatment of edentulous arch, and already included in the UHC benefit package.  Health system readiness and capacity to implement the policy is another key issue for policy making decision. 13 Policy recommendations

14. International Health Policy Program -Thailand National Health Security Office (NHSO) of Thailand, The Universal Coverage Benefit Package Subcommittee of NHSO, Ministry of Public Health (MOPH) of Thailand Institute of Dentistry of Thailand 14 Acknowledgement