摘要：Objectives. We estimated short-term health care cost savings that would result from oral health professionals performing chronic disease screenings. Methods. We used population data, estimates of chronic disease prevalence, and rates of medication adherence from the literature to estimate cost savings that would result from screening individuals aged 40 years and older who have seen a dentist but not a physician in the last 12 months. We estimated 1-year savings if patients identified during screening in a dental setting were referred to a physician, completed their referral, and started pharmacological treatment. Results. We estimated that medical screenings for diabetes, hypertension, and hypercholesterolemia in dental offices could save the health care system from $42.4 million ($13.51 per person screened) to $102.6 million ($32.72 per person screened) over 1 year, dependent on the rate of referral completion from the dental clinic to the physician's office. Conclusions. Oral health professionals can potentially play a bigger role in detecting chronic disease in the US population. Additional prevention and monitoring activities over the long term could achieve even greater savings and health benefits. About 133 million Americans, or almost 1 in 2 adults, have at least 1 chronic illness. Chronic conditions account for more than 75% of health care costs and 70% of deaths each year in the United States. 1 Chronic diseases cost the United States $153 billion annually in lost productivity, and individuals who are overweight, obese, or have other chronic conditions miss an additional 450 million days from work compared with healthy workers. 2 The high prevalence, associated morbidity, and economic impact of chronic diseases, particularly diabetes, hypercholesterolemia (high blood cholesterol), and hypertension, are a serious public health issue in the United States today. According to the Medical Expenditure Panel Survey, about 40% of adults visit the dentist in a given year, 3 10% to 20% of whom have not seen a physician in the preceding year. 4,5 This presents an opportunity for oral health professionals to be part of an integrated health care team working to combat these chronic diseases. Screening for undiagnosed medical conditions in the dental office has long been proposed as a potentially valuable public health service. 6–8 Widespread adoption of this practice is dependent on determining the efficacy of screening in the dental setting and acceptance by dental care providers and patients. To examine the effectiveness and acceptance of screening programs, several studies have evaluated screening for diabetes, hypercholesterolemia, and hypertension in the dental setting. 4,9 These conditions were chosen because of (1) their prevalence in today’s society, (2) the significant morbidity and mortality associated with these conditions, (3) the ability to lessen their burden through early detection, and (4) the availability of well-validated, safe, and easy-to-use screening tools. 4,9,10 Additional studies have found that a majority of dentists 11 and patients 12 believe that it is important for oral health professionals to perform medical screenings for heart disease, diabetes, and hypertension in the dental office. A study conducted in Sweden concluded that limiting screening to patients older than 40 years of age would increase the percentage of patients who participated in screening and who had hypertension. 13 Another study came to a similar conclusion, and also found potential benefits for patients who had been previously diagnosed with hypertension but who did not maintain adequate blood pressure control. 14 The utility of screening for diabetes during dental visits has also been evaluated. Among 356 patients with no known history of diabetes who visited an outpatient periodontal clinic in India, diabetes was found in 19.1% of the patients. 15 In practice, physicians who detect an abnormal test result for the presence of chronic disease are inclined to provide medication to their patients. The thresholds upon which primary care physicians determine mediation treatment, particularly for diabetes and hypertension, have been lowered since the early 1990s, and newer guidelines encourage the treatment of prediabetes and prehypertension. 16 In this analysis, we assumed that people who had undiagnosed diabetes, undiagnosed hypercholesterolemia, or undiagnosed hypertension and were subsequently diagnosed for 1 or more of these conditions by a physician would receive prescription drug treatment per treatment guidelines. Once patients start medication therapy, it is important that they adhere to the regimen. Medication treatment of cardiovascular disease has been shown to be effective only if patients adhere to their medication. 17 Poor medication adherence has been associated with increased hospitalization, increased use of health care resources, and higher overall health care costs. 18–20 Poor medication adherence has also been associated with failure to reach treatment target goals, (such as blood pressure control), adverse clinical outcomes, and higher rates of mortality. 17,21,22 No previous studies we know of examined the cost implications to the US health care system stemming from chronic disease screenings in a dental office. In the current environment of fiscal constraint and the focus on cost control in health care reform, potential cost savings are important to consider. In this analysis, we estimated 1 component of the overall potential health care cost savings associated with screening for medical conditions in a dental setting. Given that our calculations are based on prevalence rates for undiagnosed disease, in this scenario a positive screening test will always result in a positive diagnosis. This component comprised the 1-year cost savings associated with (1) oral health professionals’ detection of diabetes, hypercholesterolemia, and hypertension in previously undiagnosed patients; (2) their referral of those patients to a physician for diagnosis; and (3) the patients’ initiation of medication therapy. Specifically, we calculated the medical costs and appropriate pharmacy costs associated with medication adherence and nonadherence in a 12-month period after a physician’s diagnosis. Medical costs, as defined by Sokol et al., include the costs of outpatient, inpatient, and emergency room services over a 12-month period. 18 Pharmacy costs include all the costs associated with medications dispensed by an outpatient, mail-service, or community-based pharmacy over a 12-month period. 18 In our model, “health care savings” means medication health care savings during a 12-month period.
