Cochrane · intervention · CD009853
The effect of different methods of remuneration on the behaviour of primary care dentists
Brocklehurst, P, Price, J, Glenny, AM, et al. · Cochrane Database of Systematic Reviews · 2013 · Cochrane Library
Effective Practice and Organisation of CareOral HealthOther oral health2 versionsAMSTAR 2: not assessed
Full textEvery question was extracted from the full review (methods and results), not only its Summary of Findings table.
Questions
30
current version
GRADE rated
27
No studies
0
Included studies
2
as reported
No studies 0 · 0%Ungraded 3 · 10%Very low 3 · 10%Low 24 · 80%Moderate 0 · 0%High 0 · 0%
Ungraded means an effect was reported without a GRADE rating; it is not a gap. No studies means the review found nothing to answer the question. The six categories are a display order, not a score.
Review question
| Element | Planned (methods) | Found (results) |
|---|---|---|
| Population | Primary care dentists providing routine dental care in primary care environments | Primary care dentists and children in the UK: 503 dental practices, 821 dentists, 4771 patients (n=2 studies); dentists seeing children with erupted second permanent molars in deprived areas of Scotland (n=1); children 0- to 15-years-old undergoing routine continuing dental care in England and Scotland (n=1) |
| Intervention | Fee-for-service payments; Fixed salary payments; Capitation payments; Blended payments (combinations of above) | Fee-for-service remuneration (n=1); Capitation remuneration (n=1) |
| Comparison | Comparison between different methods of remuneration | No specific intervention/control (n=1); Fee-for-service remuneration (n=1) |
| Outcomes | Measures of clinical activity; Measures of health service utilisation; Healthcare costs; Patient outcomes; Measures of non-clinical behaviour of primary care dentists; Measures of dental practice profitability/income; Any unintended effects | Measures of clinical activity (n=2); Measures of health service utilisation (n=1); Healthcare costs (n=2); Patient outcomes (n=1); Measures of non-clinical behaviour (n=1); Unintended effects (n=1) |
| Study designs | Randomised controlled trials (RCTs); Non-randomised clinical trials (NRCTs); Controlled before-after (CBA) studies (at least two sites in each group); Interrupted time series (ITS) studies | Cluster-randomised controlled trials (n=2) |
| Timing | Not specified | 18 months (n=1); 3 years (n=1) |
Search date: 2013-06. Databases: Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE (Ovid); EMBASE (Ovid); EPOC Group Specialised Register; EconLit (ProQuest); PAIS International (ProQuest); CINAHL (EbscoHost); NHS Economic Evaluation Database (EED); Health Economic Evaluations Database (HEED)
Questions and results
Current version onlyFee-for-service remuneration vs No specific intervention (control)
Population: Dentists seeing children with erupted second permanent molars (Scotland, in areas representing the four most deprived categories out of seven)
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Healthcare costs: cost-effectiveness of fee-for-service vs control (incremental cost-effectiveness ratio, reported as % change in outcome per GBP; currency year NR) 18 months | ICER 0.10 | 1 study · 68 participants | Very low Downgraded: risk of bias, indirectness |
Measures of clinical activity: mean percentage of 12- to 14-year-olds receiving fissure sealants for second permanent molars per dentist (weighted by number of children seen) - unadjusted 18 months | RD 7.1 [-1.9, 16.1] 7.1 [-1.9, 16.1] percentage points higher (fissure sealant placement, unadjusted) | 1 study · 133 participants | Very low Downgraded: risk of bias, indirectness |
Measures of clinical activity: mean percentage of 12- to 14-year-olds receiving fissure sealants for second permanent molars per dentist (weighted by number of children seen) - adjusted 18 months | RD 9.8 [1.8, 17.8] 9.8 [1.8, 17.8] percentage points higher (fissure sealant placement, covariate-adjusted) | 1 study · 133 participants | Very low Downgraded: risk of bias, indirectness |
Capitation remuneration vs Fee-for-service remuneration
Population: Children (0- to 15-year-olds) undergoing routine continuing dental care at 354 dental practices, in matched pairs of Health Service administrative areas in England (northern urban, commuter suburb, rural) and Scotland
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Measures of non-clinical behaviour: proportion of dentists introducing innovations into their dental practices 3 years | RR 0.81 -13 percentage points (risk difference) | 1 study | Ungraded |
Patient outcomes: mean percentage of 0- to 15-year-olds having one or more teeth extracted 3 years · Rural community | RR 0.70 -3 percentage points (risk difference) | 1 study · 2250 participants | Low Downgraded: risk of bias |
Unintended effects: self-reported temptation to under-prescribe (0- to 100-point visual analogue scale) 3 years | MD 20.6 20.6 VAS points (0 to 100) | 1 study | Ungraded |
Measures of clinical activity: mean percentage of 0- to 15-year-olds receiving active preventive advice 3 years · Northern urban community | RR 2.42 27 percentage points (risk difference) | 1 study · 2250 participants | Low Downgraded: risk of bias |
Patient outcomes: mean number of decayed teeth per 14- to 15-year-old (data for 0- to 15-year-olds NR) 3 years · Commuter suburb community | MD 0.07 0.07 decayed teeth per 14- to 15-year-old | 1 study · 1919 participants | Low Downgraded: risk of bias |
Patient outcomes: mean number of filled teeth per 0- to 15-year-old 3 years · Commuter suburb community | MD -0.03 -0.03 filled teeth per 0- to 15-year-old | 1 study · 2250 participants | Low Downgraded: risk of bias |
Unintended effects: self-reported temptation to over-prescribe (0- to 100-point visual analogue scale) 3 years | MD -14.9 -14.9 VAS points (0 to 100) | 1 study | Ungraded |
Measures of clinical activity: mean percentage of 0- to 15-year-olds receiving active preventive advice 3 years · Rural community | RR 0.85 -5 percentage points (risk difference) | 1 study · 2250 participants | Low Downgraded: risk of bias |
Patient outcomes: mean number of decayed teeth per 14- to 15-year-old (data for 0- to 15-year-olds NR) 3 years · Scottish community | MD 0.15 0.15 decayed teeth per 14- to 15-year-old | 1 study · 1919 participants | Low Downgraded: risk of bias |
Healthcare costs: mean expenditure in GBP per 0- to 15-year-old (currency year NR) 1 year · Scottish community | MD 1.52 1.52 GBP per 0- to 15-year-old | 1 study · 276414 participants | Low Downgraded: risk of bias |
Patient outcomes: mean percentage of 0- to 15-year-olds having one or more teeth extracted 3 years · Commuter suburb community | RR 1.00 0 percentage points (risk difference) | 1 study · 2250 participants | Low Downgraded: risk of bias |
Measures of health service utilisation: mean number of visits per 0- to 15-year-old 3 years · Commuter suburb community | MD -0.4 -0.4 visits per 0- to 15-year-old | 1 study · 2250 participants | Low Downgraded: risk of bias |
Measures of health service utilisation: mean number of visits per 0- to 15-year-old 3 years · Scottish community | MD -0.5 -0.5 visits per 0- to 15-year-old | 1 study · 2250 participants | Low Downgraded: risk of bias |
Patient outcomes: mean number of decayed teeth per 14- to 15-year-old (data for 0- to 15-year-olds NR) 3 years · Rural community | MD 0.75 0.75 decayed teeth per 14- to 15-year-old | 1 study · 1919 participants | Low Downgraded: risk of bias |
Healthcare costs: mean expenditure in GBP per 0- to 15-year-old (currency year NR) 1 year · Northern urban community | MD 4.22 4.22 GBP per 0- to 15-year-old | 1 study · 276414 participants | Low Downgraded: risk of bias |
Measures of health service utilisation: mean number of visits per 0- to 15-year-old 3 years · Rural community | MD -0.3 -0.3 visits per 0- to 15-year-old | 1 study · 2250 participants | Low Downgraded: risk of bias |
Measures of clinical activity: mean percentage of 0- to 15-year-olds receiving active preventive advice 3 years · Scottish community | RR 1.32 9 percentage points (risk difference) | 1 study · 2250 participants | Low Downgraded: risk of bias |
Patient outcomes: mean percentage of 0- to 15-year-olds having one or more teeth extracted 3 years · Northern urban community | RR 0.72 -5 percentage points (risk difference) | 1 study · 2250 participants | Low Downgraded: risk of bias |
Measures of health service utilisation: mean number of visits per 0- to 15-year-old 3 years · Northern urban community | MD -0.4 -0.4 visits per 0- to 15-year-old | 1 study · 2250 participants | Low Downgraded: risk of bias |
Patient outcomes: mean number of filled teeth per 0- to 15-year-old 3 years · Scottish community | MD -0.28 -0.28 filled teeth per 0- to 15-year-old | 1 study · 2250 participants | Low Downgraded: risk of bias |
Healthcare costs: mean expenditure in GBP per 0- to 15-year-old (currency year NR) 1 year · Commuter suburb community | MD 6.18 6.18 GBP per 0- to 15-year-old | 1 study · 276414 participants | Low Downgraded: risk of bias |
Patient outcomes: mean number of filled teeth per 0- to 15-year-old 3 years · Northern urban community | MD -0.18 -0.18 filled teeth per 0- to 15-year-old | 1 study · 2250 participants | Low Downgraded: risk of bias |
Patient outcomes: mean percentage of 0- to 15-year-olds having one or more teeth extracted 3 years · Scottish community | RR 0.93 -1 percentage points (risk difference) | 1 study · 2250 participants | Low Downgraded: risk of bias |
Patient outcomes: mean number of decayed teeth per 14- to 15-year-old (data for 0- to 15-year-olds NR) 3 years · Northern urban community | MD 0.16 0.16 decayed teeth per 14- to 15-year-old | 1 study · 1919 participants | Low Downgraded: risk of bias |
Patient outcomes: mean number of filled teeth per 0- to 15-year-old 3 years · Rural community | MD -0.21 -0.21 filled teeth per 0- to 15-year-old | 1 study · 2250 participants | Low Downgraded: risk of bias |
Healthcare costs: mean expenditure in GBP per 0- to 15-year-old (currency year NR) 1 year · Rural community | MD 6.90 6.90 GBP per 0- to 15-year-old | 1 study · 276414 participants | Low Downgraded: risk of bias |
Measures of clinical activity: mean percentage of 0- to 15-year-olds receiving active preventive advice 3 years · Commuter suburb community | RR 1.83 15 percentage points (risk difference) | 1 study · 2250 participants | Low Downgraded: risk of bias |
Method of remuneration (fee-for-service, salaried, or per capita) vs An alternative method of remuneration
Population: Primary care dentists providing routine dental care for patients in a primary care environment
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Healthcare costs | no estimate extracted | NR | No studies |
Measures of patient outcomes | no estimate extracted | NR | No studies |
Measures of health service utilisation | no estimate extracted | NR | No studies |
Measures of non-clinical behaviour of primary care dentists | no estimate extracted | NR | No studies |
Measures of dental practice profitability/income | no estimate extracted | NR | No studies |
Measures of clinical activity | no estimate extracted | NR | No studies |
Any reported unintended effects of the remuneration systems (including supplier-induced demand) | no estimate extracted | NR | No studies |