Download Does Treatment of Oral Disease Reduce the Costs

Does Treatment of Oral Disease Reduce
the Costs of Medical Care?
Marjorie Jeffcoat, DMD; Nipul K. Tanna, DMD, MS; Clay Hedlund, DDS; Michael S.
Hahn, DDS; Miles Hall, DDS, MBA; Robert J. Genco, DDS, PhD
Author(s)
Marjorie Jeffcoat, DMD
Professor and Dean Emeritus, University of Pennsylvania School of Dental
Medicine, Philadelphia; Professor, Hospital of the University of Pennsylvania,
Philadelphia
Nipul K. Tanna, DMD, MS
Assistant Professor of Preventive and Restorative Sciences, University of Pennsylvania, Philadelphia
Disclosure: Nipul K. Tanna, DMD, MS, has disclosed no relevant financial relationships.
Clay Hedlund, DDS
Dental Director, CIGNA Dental, Plano, Texas
Disclosure: Clay Hedlund, DDS, has disclosed the following relevant financial relationships:
Serves as an employee of: CIGNA Dental Health, Inc.
Michael Hahn, DDS
National Dental Director, CIGNA Dental, Philadelphia, Pennsylvania
Disclosure: Michael Hahn, DDS, has disclosed the following relevant financial relationships:
Serves as an employee of: CIGNA Dental Health, Inc.
Miles Hall, DDS, MBA
Chief Clinical Director, CIGNA Dental, Plano, Texas
Disclosure: Miles Hall, DDS, MBA, has disclosed the following relevant financial relationships:
Serves as an employee of: CIGNA Dental Health, Inc.
Robert J. Genco, DDS, PhD
Distinguished Professor of Oral Biology and Microbiology, State University of New York at Buffalo, Amherst
Editor's Note
The following analysis, although not a randomized controlled trial, tests a potential, and important,
association between oral and systemic health. Data are derived from a convenience sample of insured
persons with both diabetes and periodontal disease. Although the generalizability of these results to other
populations (such as the uninsured) is not known, we believe that these findings could serve as a
springboard for further research exploring this association. This compelling preliminary analysis may
be of interest to researchers in many arenas, including dentistry, chronic disease, and healthcare costs.
Mining Insurance Data to Answer Clinical Questions
The exploratory studies needed to detect associations between clinical conditions
and potential contributing factors (demographic, environmental, genetic, or
medical) pose a special challenge in research. On one hand, large sample sizes are
needed to detect subtle influences in the presence of strong known effects (eg,
smoking) or confounders. On the other hand, the tentative nature of the hypothesis
may not justify the effort and cost of large (usually multicenter) randomized
controlled trials at an early stage of knowledge. When possible, researchers seek to
"mine" historical records as an early step in determining the credibility of a
hypothesis. We, as well as others, have found insurance records to be especially rich
and reliable sources of health data (such as healthcare costs). What they lack in
medical, dental, behavioral, and adherence detail is often offset by their uniformity
and sheer size. The trick is to formulate the research question in a way that it can be
answered from the available data.
This article discusses how data from a group of large private insurance plans were
used to investigate whether periodontal health affects the cost of medical care in
patients with type 2 diabetes. Although the findings are interesting, the process may
also be relevant to other clinicians trying to interpret reports derived from these
valuable data sources.
The Evidence: Diabetes and Periodontal Disease
Strong and growing evidence points to an association between diabetes and oral
health. One third of patients with diabetes have oral complications, mainly
periodontitis and tooth loss[1,2] and a large body of evidence suggests that periodontal
disease is a complication of diabetes mellitus.[3,4] A recent meta-analysis shows that
periodontal disease is more severe in individuals with diabetes than in individuals
without diabetes, especially in those with poor glycolic control.[5]
Perhaps more intriguing is the expanding body of literature implicating severe
periodontitis as a risk for poor glycemic control in type 2 diabetes.[6,7] Periodontitis
puts these patients at greater risk for diabetic complications, including mortality
from cardiovascular disease and diabetic nephropathy.[8,9] Periodontal treatment in
individuals with diabetes can improve glycemic control,[10,11] potentially leading to a
reduction of the effects of diabetes per se, and its complications.
Given such findings, one can easily visualize a vicious cycle in which diabetes leads
to worsening periodontal disease, and periodontal disease leads to worsening
glycemic control. Our study's hypothesis was that periodontal treatment might
contribute to the successful management of diabetes, and lead to reduced cost for
medical care.
Cost of Medical Care in Diabetes
Diabetes mellitus is a chronic illness affecting about 23.6 million people in the
United States. In 2007, direct medical expenses were estimated to be $116 billion,[12]
with an additional $58 billion in indirect expenditures related to disability, work
loss, and premature death. These costs represent approximately 20% of the total
healthcare expenditures in the United States.[13] This economic burden can be
expected to grow with projected increases in the incidence of diabetes.[14]
Insurance databases that include patients covered by both medical and dental
insurance have been used to assess the effects of dental care on medical conditions.
For example, Spangler and colleagues[15] showed that glycosylated hemoglobin was
reduced in insured individuals with diabetes who had periodontal therapy, and that
the reduction was greater with more intense periodontal treatment. Another study
that used an insurance database showed that periodontitis treatment had an impact
on medical costs for those with diabetes mellitus.[16]
Our Study: Insured People With Diabetes
This commentary presents new data from a substantial population of individuals,
with both medical and dental coverage from the same carrier (CIGNA,
Philadelphia, Pennsylvania). For the analysis, insured persons with diabetes were
divided into 2 groups:


Those who had received treatment for their periodontal disease and were
well maintained; and
Those who did not complete periodontal treatment or maintenance.
The medical costs in each of these groups 2 years after the periodontal treatment
were compared to test the hypothesis that periodontal treatment was associated with
a reduction in the cost of medical care in patients with diabetes. This retrospective
study used a merged medical and dental claims database (stripped of patient
identifiers) and was classified as exempt by the University of Pennsylvania
Institutional Review Board. The data covered a 3-year period (2006-2008), and
included 46,094 patients.
In addition to medical costs, the database included the medical diagnostic group
Episode Treatment Group® (ETG®, Ingenix, Eden Prairie, Minnesota), and dental
procedure codes. To be eligible to be included in this analysis, the medical
practitioner must have classified the patient as having diabetes (ETG 1630) in the
year 2006.
Because dental diagnostic codes are not currently in use, a presumptive diagnosis of
periodontal disease was made if there was evidence of active periodontal therapy
using the CDT dental procedure codes (D4210, D4211, D4240, D4241, D4245,
D4260, D4261, D4263, D4264, D4265, D4266, D4267, D4274, D4341, D4342, D4381,
and D4910). The first group included patients who received active periodontal
therapy in 2006 and were well maintained thereafter (active periodontal treatment
group). The second group included patients who received 1 or 2 procedures for
treatment (usually incomplete scaling and root planing) of their periodontal disease
before or during 2006, but did not complete their periodontal care or seek regular
maintenance thereafter (control group). Both groups of patients were assumed to
have periodontal disease, because they received at least some periodontal therapy.
Patients in either of these groups may have been treated by a dentist for other
conditions, including restorative needs.
Comparison of Medical Costs
The active periodontal treatment group received periodontal care in 2006 and
maintenance therapy from 2006 to 2008. The control group did not follow through
with periodontal care, including maintenance. A multifactorial analysis of variance
was performed. Independent variables included age (in 2006), sex, and periodontal
treatment (active periodontal treatment or control group). The dependent variable
was the total cost of medical care in 2008 (2 years after active periodontal
treatment). The results are shown in the figure (Figure).
Figure. Medical costs before and after periodontal treatment.
Medical costs did not differ between the 2 groups for the baseline year, 2006. In
2008, the control group had significantly higher medical costs than the active
periodontal treatment group. (P = .021). A mean yearly savings of $2483.51 per
patient was realized, independent of age. These savings occurred 2 years after
periodontal treatment, suggesting that periodontal treatment had a lasting effect on
these patients with diabetes. In men, the savings were $3212.36 in medical costs per
patient, favoring the periodontal treatment group (P < .03). In women, the savings
were smaller ($735.27 per patient) but still significant (P < .05).
Advantages and Limitations of Existing Databases
Mining existing databases can be highly cost-effective in research. Insurance data
have several advantages:


They are generally well-organized and accurate;
They can be automatically and blindly stripped of identifiers for use in
hypothesis testing (as the present study);




They usually contain important demographic information that is necessary
to control the analysis;
When medical and dental coverage are provided from the same carrier,
investigating the relationship between oral and systemic health is greatly
facilitated;
They offer large sample sizes; and
They provide solid, comparative data on costs, so that in this age of
healthcare reform we are able to provide data to make the case that dentistry
is cost-effective care.
Of course, the approach has some major limitations. Databases intended for other
purposes (such as billing and audit functions) rarely contain all the information we
would wish to have, such as probing depths, medical laboratory values, adherence to
treatment protocols, or other behavioral factors. The most glaring deficiency is the
absence of dental diagnostic codes, which forces us to use procedure codes as a
surrogate for diagnosis. Furthermore, the findings of these studies do not show
cause and effect, only an association between the variables of interest.
Summary of Findings
The time for isolating diseases of the oral cavity from the rest of the body has long
passed. Clearly, long-term healthcare costs are significant for a chronic disease such
as diabetes with oral disease complications. In 2008, the American Diabetes
Association (ADA) reported that diabetes was among the 10 most expensive diseases
and chronic conditions in the United States.[2,17]
The ADA also estimates that an average of $11,744 is spent per year for the care of a
patient with diabetes, whereas only $3145 to $5872 is estimated to be spent on
patients who do not have diabetes.[2,17] In this study, an average of $10,672 was spent
for medical care for patients with diabetes who did not have periodontal treatment.
These costs are comparable to the ADA's estimates. The ADA data provide evidence
of the reliability of our estimates of medical care costs.
We found an average reduction of $2483 per year per patient, or an average savings
of 23%, with periodontal treatment. Therefore, treatment of periodontal disease
could make a significant contribution in containing healthcare costs, especially in
patients with diabetes. These results, if found to be similar in other populations,
provide a basis for coordinated care of patients with both diabetes and periodontal
disease.
References
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mellitus and oral soft tissue pathologies. Part 1: prevalence and
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