From Volume 10, Issue 1, January 2017 | Pages 32-36
The orthognathic service in some areas of the UK have come under increased pressure due to financial constraints within the NHS. The authors felt it was timely to investigate the cost to the NHS of orthognathic treatment for patients at a District General Hospital (DGH).
In the UK National Health Service (NHS) orthognathic treatment tends to be carried out within the hospital-based services. In these times of continued austerity, the Government has released procedures which were deemed low priority, one of which was orthognathic surgery for purely aesthetic purposes.
Previous studies have shown orthognathic surgery to provide good outcomes for a relatively low cost,1 with other studies showing the cost of combined orthodontic/orthognathic treatment to be approximately US $6,2002–€6300.00,3 based on materials, staff and facilities costs. These studies were performed in Finland and the UK, respectively.
An American study has also identified the cost of the surgery alone (patient charges) ranging from $4778–$8816, for bimaxillary osteotomies, $3538–$6784, for Le Fort I osteotomies, and $3086–$5023 for bilateral sagittal split osteotomies4
Owing to the financial constraints of the NHS, these services are coming under increased pressure. Public Health England, on behalf of NHS England, published interim guidance in November 2013,5 This report stated that it wished to remove healthcare inequalities between regions, as neighbouring regions may have had different policies on the type of malocclusions that would qualify for funding within the NHS.
Orthognathic treatment has psychosocial benefits, including improved self-confidence, body and facial image, and social adjustment.6 Given the context of service efficiency, value for money and quality, it is important to ask questions about the costs, affordability, desire and effects of orthognathic treatment. Therefore, studies that assess the cost, efficacy and efficiency need to be performed. This will aid in resource allocation for the greatest benefit of the population as a whole.7
Therefore, it was deemed appropriate to ascertain the cost of orthognathic treatment to the NHS for patients who are treated at a District General Hospital (DGH) and to see if this falls within established figures and if there were any factors that may increase the cost or duration of treatment.
The aim of this study was to investigate:
Retrospective analysis of all patients treated in a DGH, who had orthognathic surgery from March 2007 to July 2012.
Patients were identified by the use of an electronic logbook of all orthognathic patients, which was populated when a patient received an operation date.
The following patients were excluded from the analysis:
Data were collected retrospectively by one operator. Orthodontic clinical notes and medical notes were manually analysed and data inputted into a spreadsheet within Microsoft Excel (2007) as shown in Appendix 1.
These data were used to calculate the cost to the NHS for combined treatment using the Payment by Results fee document 2012–20138 (which sets the typical fee paid by the NHS to hospitals for appointments/interventions).
Data were analysed using Microsoft excel 2007 and IBM SPSS version 22.
Eighty-four patients met the inclusion criteria. The median age at the time of orthognathic surgery was 19 years and 1 month, with a range of 16 years and 4 months to 60 years and 4 months.
All patients treated had an IOTN DHC of 4 or 5, with 54.8% having an IOTN DHC of 4 and 45.2% having an IOTN DHC of 5.
Table 1 shows that the majority of orthognathic patients treated had a Class III incisal relationship on a skeletal III base.
| Incisal relationship | |||||
|---|---|---|---|---|---|
| I | II div 1 | II div 2 | 3 | ||
| Skeletal AP | I | 2 | 0 | 0 | 0 |
| II | 0 | 26 | 3 | 2 | |
| III | 1 | 0 | 0 | 50 | |
Figure 1 shows the overjet subdivided by the incisal relationship, with the range being treated from 15 mm–7 mm.
Table 2 shows that, of the 20 patients who had an AOB, 17 had an increased FMPA, whereas, of the 26 patients that had an increased overbite (OB), only 8 had an increased FMPA and 12 had a decreased FMPA.
| OB | AOB | |||||
|---|---|---|---|---|---|---|
| Average | Decreased | Increased | No | Yes | ||
| FMPA | Average | 6 | 7 | 6 | 19 | 3 |
| Decreased | 1 | 0 | 12 | 13 | 0 | |
| Increased | 2 | 20 | 8 | 31 | 17 | |
All patients were treated using conventional pre-adjusted edgewise appliances.
The mean number of pre-operative visits was 17.6 (SD 5.69), mean number of post-operative visits was 7.21 (SD 2.38), and the median number of emergency appointments was 2 (range 0–8).
Only 39 patients had completed the 2-year retention monitoring period within this study; the mean number of visits was 3.29 (SD 1.12).
The mean number of visits to the maxillofacial department was 3.89 (SD 1.76).
The median number of joint clinic appointments was 2 (Range 1–5).
The mean computer-predicted surgical movements are shown in Table 3. The range of predicted movements within the mandible were at the start of treatment (-12 mm–10 mm) and pre-operative (-12 mm–8 mm). The range of predicted movements within the maxilla were at the start of treatment (-2 mm–9 mm) and pre-operative (-2 mm–8 mm).
| Incisors | ||||
|---|---|---|---|---|
| 1 | 2 div 1 | 2 div 2 | 3 | |
| Mean | Mean | Mean | Mean | |
| Movement maxilla AP start of treatment | N/A | 2 | 2 | 4 |
| Movement maxilla AP pre-operative | 3 | 1 | 0 | 4 |
| Movement mandible AP start of treatment | N/A | 6 | 7 | -5 |
| Movement mandible AP pre-operative | 2 | 4 | 6 | -5 |
The mean length of time for orthognathic surgery was 4.09 hours (SD 1.198).
The mean in patient stay time was 3 days (SD 0.76), range 2–6 days. One patient was taken back to surgery 2 weeks after the initial operation, and 4 patients had SARPE (Surgically Assisted Rapid Palatal Expansion).
Five different plating systems were used during the study period (AO matrix, AO compact, AO synthes, Medartis vario and Stryker), with the plating system having no impact on surgical time or complication rate.
The total time for treatment followed a normal distribution with a mean treatment time of 28.33 months (SD 8.25). The mean pre-operative time was 22.27 months (SD 6.83), and the median post-operative time was 5 months (range 3–21). The only predictor of treatment time was the number of appointments at each stage of treatment; all other factors were not statistically significant.
Orthodontic care during the study was provided by 4 consultants and 2 senior specialist registrars, with no correlation between clinician grade and time to complete treatment or cost of treatment.
Recorded within the clinical notes, 30% of patients had paresthesia after 1 year; in 16% of patients paresthesia resolved within 1 year and 54% had no mention of paresthesia within the clinical notes; 7% had one or more plates removed and one patient experienced post surgical condylar resorption.
The cost of orthodontic treatment, as measured by the payment by results (PBR) tariff, is displayed in Figure 2. The histogram shows a non-normal distribution with a negative skew. The median cost was £2075.00, with a range of £1245.00–£4067.00.
The cost of the combined treatment excluding retention visits is displayed in Figure 3. The histogram follows a normal distribution with a mean cost of £6456.57 (SD £613.79).
When statistical analyses were performed, the only predictive factor for the cost of orthodontic treatment or the combined treatment was the number of appointments required to complete the treatment.
The study was performed retrospectively and data were retrieved from the patient's orthodontic file and from the hospital file, which contained the maxillofacial entries. As with all retrospective studies, this study was subject to recall bias, whereby if an entry was not recorded or recorded incorrectly within the notes, this would affect the cost analysis as this was extrapolated from the number of appointments. Previous cost analysis studies have focused on cost based on staff/facilities and consumables, whereas this study analysed the cost as paid by the NHS on the PBR tariff (2012–2013). This study therefore provides the cost to the NHS rather than the actual real-term cost of providing the treatment. This may be more relevant as it enables the commissioners of the service to have an idea of the typical cost within the UK, which may enable more accurate planning of resource deployment.
Within this study, no predictive factors were found other than the number of appointments. It may be speculated that patients with a Class III skeletal pattern or AOB may have an increased treatment time due to difficulties in visualizing arch co-ordination. In Class II cases, patients may be asked to posture into a Class I incisal relationship, minimizing the requirement for impressions to check arch co-ordination. (This facility is not available in patients with AOB or Class III, therefore it would seem a logical assumption that these patients would have an increased treatment time.) However, this was not the case. This may be due to no real difference existing or that the sample size was not sufficient to demonstrate a difference.
Another factor that has been demonstrated to increase treatment time is breakages.9,10,11 An author in a retrospective analysis of his own practice reporting treatment time to be on average 2.8 months longer and requiring 1.5 appointments more if the patient had a bracket failure.10 The author also reported that, for every bracket failure, treatment time was increased by 1.21 months and 0.77 appointments.10 The median number of emergency appointments within this study was 2 with no statistically significant relationship between emergency appointments and treatment length. This may be because the study only recorded the number of emergency appointments and did not collect data on bracket failure at routine appointments; therefore the data may not be truly representative of the number of breakages that occurred.
Within this study, no predictive factors were found other than the number of appointments. No previous studies were found that measured the cost of orthognathic treatment via a PBR tariff, therefore the only possible comparison that could be made was with previous published studies based on the cost of staff/facilities and consumables.
A previous study3 that was performed based on staff/consumables and facilities cost showed that the following factors had a predictive value for treatment cost:
However, with the PBR tariff the same amount of money is paid regardless of the first three factors and also whether the surgery is bimaxillary or single jaw. The only predictive factor, once these are excluded, is the number of appointments, which concurs with the findings of this study.
Compared to previous research based on staff/facilities and consumables, the cost in this study is greater; £6,456.57 compared to US $6,200,2 €6,300.00.3 However, these studies used historic financial data (1999 and 2000, respectively) compared with this study (2012) and inflation during this time period has had a significant effect, with inflation within the UK between 2000 and 2012 recorded at 42.66%.12 Therefore, if the cost in this study is compared to the other study within the UK,3 and inflation is included within the analysis, the cost of orthognathic treatment has decreased from £7,395.11 to £6,456.57. This potential change may reflect an increase in efficacy and a consequent reduction in cost to the health service.
The NHS England draft guidelines state that patients who are eligible for orthognathic treatment on the NHS should have an IOTN of 4 or 5 with functional difficulties.5 Within this study all patients who had orthognathic treatment had an IOTN of 4 or 5. However, when data collection was performed it was not always recorded if the patient had functional difficulties. During the period of the study (2007–2012), the DGH acceptance criteria for orthodontics and orthognathic surgery was patients with an IOTN of 4 or 5 whose occlusion could not be corrected with orthodontics only.
Due to the retrospective nature of this study, it would be beneficial to perform a prospective study to minimize possible biases. It would also be beneficial to perform the study over multiple centres to increase the sample size achieved. Another area that could be explored would be to compare the cost via the PBR model and the cost based on staff/facilities and consumables within the same study.
Orthognathic services within the DGH were found to be efficient and to conform to the draft Department of Health orthognathic guidelines. The mean treatment time was 2.3 years and the only predictive factor for cost and duration of treatment was found to be the number of appointments.
