Socioeconomic disparities in orthodontic treatment outcomes and expenditure on orthodontics in England\u2019s state-funded National Health Service: a retrospective observational study

Juliet Price,Stephen Birch,Paul Brocklehurst,William Whittaker,Martin Tickle

doi:10.1186/s12903-017-0414-1

Juliet Price, Stephen Birch + Show 3 more

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https://doi.org/10.1186/s12903-017-0414-1

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Abstract

BackgroundThis study aimed to assess whether there are potential areas for efficiency improvements in the National Health Service (NHS) orthodontic service in North West England and to assess the socioeconomic status (SES)-related equity of the outcomes achieved by the NHS.MethodsThe study involved a retrospective analysis of 2008–2012 administrative data, and the study population comprised patients aged ≥10 who started NHS primary care orthodontic treatment in North West England in 2008. The proportions of treatments that were discontinued early and ended with residual need (based on post-treatment Index of Orthodontic Treatment Need [IOTN] scores that met or exceeded the NHS eligibility threshold of 3.6) and the associated NHS expenditure were calculated. In addition, the associations with SES were investigated using linear probability models.ResultsWe found that 7.6% of treatments resulted in discontinuation (which was associated with an NHS annual expenditure of £2.3 m), and a further 19.4% (£5.9 m) had a missing outcome record. Furthermore, 5.2% of treatments resulted in residual need (£1.6 m), and a further 38.3% (£11.6 m) had missing IOTN data (due to either a missing outcome record or an incomplete IOTN outcome field in the record), which led to an annual NHS expenditure of £13.2 m (44% of the total expenditure) on treatments that are a potential source of inefficiency. Compared to the patients in the highest SES group, those in the lower SES groups were more likely both to discontinue treatment and to have residual need on treatment completion.ConclusionsSubstantial inefficiencies were evident in the NHS orthodontic service, with 7.6% of treatments ending in discontinuation (£2.3 m) and 5.2% ending with residual need (£1.6 m). Over a third of cases had unreported IOTN outcome scores, which highlights the need to improve the outcome monitoring systems. In addition, the SES gradients indicate inequity in the orthodontic outcomes, with children from disadvantaged communities having poorer outcomes compared to their more affluent peers.

Highlights

This study aimed to assess whether there are potential areas for efficiency improvements in the National Health Service (NHS) orthodontic service in North West England and to assess the socioeconomic status (SES)-related equity of the outcomes achieved by the NHS
A number of studies, which were largely hospital-based studies, have highlighted the potential for suboptimal outcomes in the NHS orthodontic service in England and Wales. These studies have focused on both discontinuation [6, 7] and suboptimal outcome scores based on occlusal indices such as the Index of Orthodontic Treatment Need (IOTN) [8], the Index of Complexity, Outcome, and Need (ICON) [8, 9], and the Peer Assessment Rating (PAR) index [8, 10]
The study involved a retrospective analysis of data from 1 January 2008 to 31 December 2012 from all orthodontic activity records (i.e., FP17O records) submitted by primary care dentists who were working under state-funded NHS contracts in North West England [12]

Summary

Introduction

This study aimed to assess whether there are potential areas for efficiency improvements in the National Health Service (NHS) orthodontic service in North West England and to assess the socioeconomic status (SES)-related equity of the outcomes achieved by the NHS. A number of studies, which were largely hospital-based studies, have highlighted the potential for suboptimal outcomes in the NHS orthodontic service in England and Wales. These studies have focused on both discontinuation (i.e., failure to complete a course of active treatment) [6, 7] and suboptimal outcome scores based on occlusal indices such as the Index of Orthodontic Treatment Need (IOTN) [8], the Index of Complexity, Outcome, and Need (ICON) [8, 9], and the Peer Assessment Rating (PAR) index [8, 10] (the PAR index was developed as a simple tool for assessing the orthodontic outcomes of groups of patients, rather than individual patients and, as part of the NHS orthodontic outcome monitoring system, providers are required to report PAR scores for 20 patients plus 10% of the additional patients [11]). A hospital-based study in England found a positive association between deprivation and ‘low or no improvement in occlusion’ (defined as a score lower than the sample median ICON improvement score of a modified version of the ICON), based on an analysis of 135 12- to 16-year-olds treated for 1 year with fixed orthodontic appliances [9]

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