Health State Utilities of Periodontitis Patients Before and After Dental Treatment Tuti Ningseh Mohd-Dom 1 BDS (Malaya), MPH (Michigan), PhD (UKMalaysia) Co-authors: Sharifah Ezat Wan Puteh 2 , Rasidah Ayob 3 , Syed Mohamed Aljunid 2 1 Faculty of Dentistry, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia, 2 Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia, 3 Oral Health Division, Ministry of Health, Malaysia, Putra Jaya, Malaysia
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Health State Utilities of Periodontitis Patients Before and After Dental TreatmentTuti Ningseh Mohd-Dom1 BDS (Malaya), MPH (Michigan), PhD (UKMalaysia)
Co-authors: Sharifah Ezat Wan Puteh2, Rasidah Ayob3, Syed Mohamed Aljunid2
1Faculty of Dentistry, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia, 2Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia, 3Oral Health Division, Ministry of Health, Malaysia, Putra Jaya, Malaysia
What is a health state?
An individual’s levels of functioning within a set of health domains such as mobility, cognition, pain, emotional functioning, self-care etc.
Valued as utilities, which is a measure of one’s goodness of life
Perfect health = 1.0, dead = 0.0
The EuroQoL EQ-5D-3LA standardised non-disease-specific instrument for describing and valuing health-related quality of life (Brooks 1996)
Purposefully developed to generate a generic index of health that places health states on scale from zero (worst health) to one (best health)
Components 0f EQ-5D-3LThe EQ-5D-3L essentially consists of 2 components
(1) the EQ-5D descriptive system and the (2) EQ visual analogue scale (EQ VAS)
The EQ-5D-3L descriptive system comprises the following 5 dimensions: mobility, self-care, usual activities, pain/discomfort and anxiety/depression.
Each dimension has 3 levels: no problems, some problems, extreme problems.
• An EQ-5D health state (or profile) is a set of observations about a person defined by the descriptive system
• There are 243 possible health states• This example identifies the state 11123• An EQ-5D health state may be converted
to a single summary index (utilities)
The Visual Analogue Scale
As an outcome measure, uses of values (utilities) include:1. Societal resource allocation: priority setting
across proposed programs or interventions2. Societal (programmatic) audit: evaluation of
ongoing activities/programs3. Personal clinical decisionsMain advantage: to compare outcomes or values of disparate healthcare programmes or interventions
Quality-adjusted life years (QALYs)
Is an outcome measure that takes into account both the quantity and the quality of the extra life provided by a health care intervention It is the health state utility value (quality) multiplied by life expectancy of a person (quantity)It provides a common currency to assess the extent of particular benefits gained from a variety of interventions in terms of health related quality of life and survival for the patient
Quality-adjusted tooth years (QATYs)
1. A tooth that has been diseased and has undergone treatment will be able to function and survive for a number of years (quantity)
2. But patient may experience some side effects such as tooth hypersensitivity or impaired aesthetics (quality)
3. The concept of QATYs is introduced to measure the status of teeth that have undergone treatment (it may not be able to function as a perfectly healthy tooth) Birch 1986, Antzak-Bouckams 1987.
Quality-adjusted tooth years (QATYs)
Is an outcome measure which is a dental analogous of QALY. It is a measure of quality of tooth in relation to its tooth life expectancy, rather than quality of life of the individual.
Value scale:Perfect health = 1.0, Tooth extracted = 0.0
Aim: To assess the effectiveness of periodontal treatment provided at selected government specialist dental clinics using patient-reported outcomes. Specific objectives: 1. To determine the oral health-related quality of life of patients newly-
diagnosed with periodontitis2. To determine the health state utilities of patients newly-diagnosed with
periodontitis3. To contrast the oral health-related quality of life and health state utilities of
newly-diagnosed periodontitis patients with that after completing cause-related periodontal treatment
This study was a part of a larger study investigating cost-effectiveness of periodontal therapy
METHODS
Newly-diagnosed periodontitis
Patient-reported outcomes
(12-months follow-up)
Clinical parameters
Cost analysis
Patient recruitment
All periodontic clinics in the Ministry of Health
Five clinics in Peninsula Malaysia randomly sampled
Periodontal therapy
COST EFFECTIVENESS ANALYSIS
STUDY FLOW
PATIENTSNew adult patients attending periodontics clinic for management of chronic/ aggressive periodontitis (has a Basic Periodontal Examination code 3 or 4 in at least one sextant on clinical examination) Patients who have not had any extensive periodontal treatment (including sub-gingival scaling) within six months prior
(1) Clinical parameters
(2) Presence / Missing teeth
(6) Periodontal pocket depth
(4) Gingival recession
(5) Clinical attachment level
(1) Bleeding on probing (degree of inflammation)
(3) Degree of Tooth mobility
(2) Oral Health Impact Profile (OHIP-14) Slade & Spencer, 1994, Saub et al 2005, 2007
(1) Functional limitation • Difficulty in chewing• Bad breath
(2) Physical pain• Ulcers• Uncomfortable to eat
(4) Physical disability• Avoid certain food• Avoid smiling
(6) Social disability• Avoid going out• Daily activities
(7) Handicap• Spent a lot of money• Felt less confident
(3) EQ-5D-3L Euro-QoL; Brooks 1996
(a) Descriptive system: Have your dental conditions caused you problems in (1 no/ 2 some/ 3 extreme):
(b) Visual Analogue Scale (0-100)
Mobility Self care Usual activities
Pain, discomfort
Anxiety, depression
EQ-5D-3L has been validated in Malay language to be used among Singaporeans (Wee et al 2007) as well as Malaysians (Shafie et al 2011)
Sample size estimation : Two means formula
n=[ 2 (s2) / d2] (zα + zβ)2 zα = 1.96 because α is set at 0.05, zβ = 0.84 because β is set at 0.20 (power 80%)s = 10.76 (standard deviation of OHIP score of periodontitis patients before treatment , Ng et al 2006)
d = 5 (minimal important difference, derived from mean change OHIP scores divided by standard deviation of change scores, Locker et al 2004)Hence, n = [2 (10.76)2 / (5)2 ] (1.96+0.84)2 = 73 patients Giving allowance for loss to follow up of q=55 -60% (Locker et al 2004,
Bajwa et al 2007), estimated total sample size= 73/(1-q)= 73/0.40 = 182.5 185
Specialist periodontal treatment
Background of sample cohort
• Total sample was 165 patients, about 20% loss to follow-up• There were more women than men. About half studied at least up to
secondary school and the rest had tertiary education. Their mean age was 43.3 (S.D 11.3) years old.
• Only about one-third worked as professionals, while the others either had non-professional occupations or were unemployed. Majority were Malay and earned at least up to the average capita Gross Domestic Product (GDP).
• Chronic periodontitis patients outnumbered aggressive periodontitis cases by a four-fold.
• For chronic periodontitis patients, most exhibited moderate periodontitis, followed by severe while very few were mild.
• All cases of aggressive periodontitis are considered severe.
Indicators Pre-treatment
Post-treatment
Test statistic
P-value 95% confidence
interval
Prevalence: % of people reporting 1+ impacts fairly/very often
130 (78.8) 52 (31.5) - *< 0.0001 -
Extent: mean number of items reported fairly/ very often (S.D)
3.3 (3.2) 1.3 (2.1) 8.2 # < 0.0001 1.5, 2.5
Severity: mean S-OHIP14 score (S.D)
20.3 (10.5) 12.7 (10.7) 10.8 # < 0.0001 8.1, 11.8
Results (1) Prevalence, severity and extent scores of oral health impacts (OHIP-14), pre- versus post-treatment
Intention-to-treat analysis, level of significance α = 0.05, * Mc Nemar test, # Paired t-test
Results (2) Mapping of EQ-5D health states with utility values
Thai population weights were used to convert
health states to an EQ-5D index score
EQ-5D-3L health states Pre-treatment (n, %)
Post-treatment (n, %)
P-value
Perfectly healthy 67 (40.6) 115 (69.7) *<0.001
Less than healthy (Other states)
98 (59.4) 50 (30.3)
Level of significance α = 0.05, * Mc Nemar test
Results (3): EQ-5D-3L health states, pre- versus post-treatment
Results (4): Improvement in EQ-5D descriptive items, pre- vs. post-treatment
Intention-to-treat analysis, level of significance α = 0.05, *Mc Nemar test
I. Quality-adjusted life year (QALY), pre- vs. post-treatment
Results (5): QALY and QATY, pre- vs. post-treatment
II. Quality-adjusted tooth year (QATY), pre- vs.. post-treatment
Items Pre-treatmentMean (S.D)
Post-treatmentMean (S.D)
Gain in QALYMean (S.D)
EQ5D utilities 0.81 (0.19) 0.91 (0.14) -
Life expectancy 35.76 (10.9) 35.76 (10.9) -
QALY* 28.92 (11.3) 32.72 (11.6) 3.8 (8.0)+
Level of significance α = 0.05, *Paired t-test, P<0.001+Median gain in QALY=0.00, IQR=10.1, Wilcoxon Signed Rank Test, P<0.001
Sites with PPD ≥ 4 mm (%) 32.7 (20.6) 23.2 (20.2) <0.0001
Probing pocket depth (PPD) (mm; mean and SD) 3.2 (0.9) 2.7 (0.9) <0.0001
Gingival recession (REC) (mm; mean and SD) 0.8 (0.8) 0.9 (0.9) <0.0001
Clinical attachment level (CAL) (mm; mean and SD) 4.0 (1.3) 3.7 (1.3) <0.0001
Results (6): Clinical parameters, pre- vs. post-treatment
Conclusions
The use of health state utilities as a measure of periodontal treatment outcome demonstrated effectiveness of treatment, consistent with improvements in clinical measures. Its use should be considered in economic evaluation of dental treatments.
Thank you
05/03/2023 28
AcknowledgementsMinistry of Health Malaysia
Ministry of Higher EducationFaculty of Dentistry, UKMFaculty of Medicine, UKM
