Cost-effectiveness of Dental Workforce Expansion Through the National Health Service Corps and Its Association With Oral Health Outcomes Among US Children

Abstract

Importance: Despite considerable efforts to improve oral health for all, large disparities remain among US children. A dental professional shortage is thought to be among the determinants associated with oral health disparities, particularly for those residing in underserved communities.

Objective: To evaluate the cost-effectiveness of expanding the dental workforce through the National Health Service Corps (NHSC) and associations with oral health outcomes among US children.

Design, setting, and participants: A cost-effectiveness analysis was conducted to estimate changes in total costs and quality-adjusted life years (QALYs) produced by increasing the NHSC funding for dental practitioners by 5% to 30% during a 10-year period. A microsimulation model of oral health outcomes using a decision analytic framework was constructed based on oral health and dental care utilization data of US children from 0 to 19 years old. Data from the nationally representative National Health and Nutrition Examination Survey (NHANES, 2011-2016) were linked to county-level dentist supply and oral health professional shortage areas (HPSAs) information. Changes in prevalence and cumulative incidence of dental caries were also estimated. Sensitivity analyses were conducted to assess the robustness of results to variation in model input parameters. Data analysis was conducted from August 1, 2021, to November 1, 2022.

Exposures: Expanding dental workforce through the NHSC program.

Main outcomes and measures: Changes in total QALYs, costs, and dental caries prevalence and cumulative incidence.

Results: This simulation model informed by NHANES data of 10 780 participants (mean [SD] age, 9.6 [0.1] years; 5326 [48.8%] female; 3337 [weighted percentage, 57.9%] non-Hispanic White individuals) found that when funding for the NHSC program increased by 10%, dental caries prevalence and total number of decayed teeth were estimated to decrease by 0.91 (95% CI, 0.82-1.00) percentage points and by 0.70 (95% CI, 0.62-0.79) million cases, respectively. When funding for the NHSC program increased between 5% and 30%, the estimated decreases in number of decayed teeth ranged from 0.35 (95% CI, 0.27-0.44) to 2.11 (95% CI, 2.03-2.20) million cases, total QALY gains ranged from 75.76 (95% CI, 59.44-92.08) to 450.50 (95% CI, 434.30-466.69) thousand QALYs, and total cost savings ranged from $105.53 (95% CI, $70.14-$140.83) to $508.23 (95% CI, $598.91-$669.22) million among children residing in dental HPSAs from a health care perspective. Benefits of the intervention accrued most substantially among Hispanic children and children in low-income households.

Conclusions and relevance: This cost-effectiveness analysis using a decision analytic model suggests that expanding the dental workforce through the NHSC program would be associated with cost savings and a reduced risk of dental caries among children living in HPSAs.

Figure 1.. Model Schematic and Dental HPSA Counties in the US

Illustration of the simulation model with a map representing county-level dental HPSAs. The map is not generated with the direct outputs of the restricted NHANES data. HPSAs refers to health professional shortage areas; NHANES, the National Health and Nutrition Examination Survey; and NHSC, National Health Service Corps.

Figure 2.. Simulated Outcomes of Increasing the National Health Services Corps Program Budgets by 10%

Results were obtained from 10 000 iterations with Monte Carlo sampling, generating 95% credible intervals (whiskers) from the simulation model. These estimates are not direct outputs of the restricted NHANES data. Error bars indicate 95% credible intervals. FPL refers to the federal poverty level, and NHANES to the National Health and Nutrition Examination Survey.

Figure 3.. One-way Sensitivity Analysis Results on Incremental QALYs and Cost

Results were obtained from 10 000 iterations with Monte Carlo sampling from the simulation model. These estimates are not direct outputs of the restricted NHANES data. NHANES refers to the National Health and Nutrition Examination Survey; NHSC, National Health Services Corps; and QALY, quality-adjusted life years.