Assessment of a framework for the allocation of primary dental services

Abstract

Philosophiae Doctor - PhDBackground: Standardized and evidence-based resource allocation frameworks for timely provision of primary dental services may support equitable distribution of comprehensive dental care. However, such frameworks, which can be applicable to primary care settings in Brazil, are not available. The purpose of this study was to explore the complex issue of equity allocation of dental staff for primary dental care services, by estimating time to dental disease progression in order to analyze costs when survival targets are set for patients waiting for primary dental care. The inclusion of wait time benchmarks for dental services in the design of the framework was an attempt to increase knowledge on the quality of access experienced by people living within catchment areas of the Family Health Strategy in Brazil. In view of ever scarce resources for public health services, ethical dilemmas arise in resource allocation when allocation choices require priority setting among individuals who face similar health needs. Since equity of access must be assured for all Brazilian citizens, the present study proposed a rational resource allocation model to help decision-makers in reconciling equity access and budgets. Aim: This study aimed to compare equity of access to dental services and costs of dental staff of two models for primary care settings. Additionally, staffing requirements and staff costs were projected over a three-year time period. Both models comprised three inter-related components: (i) universal access to oral health care, (ii) comprehensiveness of primary dental care and (iii) equity of access to primary dental services. Method: The present study was part empirical and part modeling in design. In the empirical phase, a set of maximum wait times for dental care determined by experts (Model 1) vs. wait times derived from survival analysis (Model 2) was compared. A one-year follow-up of a cohort of dental patients assigned to five primary health care clinics was conducted. The event of interest was clinical deterioration in the waiting time for dental visits. At each consultation with a dentist either for routine or emergency reasons, the oral quadrants of the patient were assessed and classified according to their urgency for dental care (from 1, less urgent to 5, more urgent). In the modeling phase, costs of dental staff were estimated on the basis of survival probabilities found in Model 1 and on survival targets simulated in Model 2. The amount of staff required as calculated by combining data on: dental service needs, activity standards for dental services, workload components in dental care, cost per working hour of dental staff, and probabilities of clinical deterioration in the wait for dental visits. Main Findings: In Model 1 (wait times determined by experts), survival probabilities were found to be unevenly distributed between diagnostic categories: category 4= 0.939 (SE 0.019); category 3= 0.829 (SE 0.035); category 2= 0.351 (SE 0.061) and category 1= 0.120 (SE 0.044). The cost of dental staff in Model 1 was estimated to be R$104 110.88 (BRL). In cost simulations of Model 2, where wait times were derived from the survival analysis study, a similar 0.900 survival probability target for all sampled quadrants (n=7 376) was found regardless of their final classification in the study year. The resulting cost of Model 2 was R$99 305.89 (BRL). Conclusions: From an equity-access perspective, the survival analysis concluded that wait times for dental visits determined by the experts may engender inequitable survival probabilities for oral quadrants classified in different diagnostic categories. From a dental-staff costs perspective, one concluded that less resources were required by setting an equitable 90% survival target for all oral quadrants studied