{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,1,7]],"date-time":"2026-01-07T14:45:36Z","timestamp":1767797136579,"version":"3.49.0"},"reference-count":40,"publisher":"BMJ","issue":"12","license":[{"start":{"date-parts":[[2025,12,29]],"date-time":"2025-12-29T00:00:00Z","timestamp":1766966400000},"content-version":"unspecified","delay-in-days":28,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"funder":[{"DOI":"10.13039\/100006545","name":"National Institute on Minority Health and Health Disparities","doi-asserted-by":"publisher","award":["R00MD016895"],"award-info":[{"award-number":["R00MD016895"]}],"id":[{"id":"10.13039\/100006545","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open"],"accepted":{"date-parts":[[2025,12,19]]},"published-print":{"date-parts":[[2025,12]]},"abstract":"<jats:sec>\n                    <jats:title>Objective<\/jats:title>\n                    <jats:p>Pay-for-performance (P4P) programmes are increasingly implemented in healthcare to improve quality of care, but their application in dentistry remains limited. Evidence-based approaches are needed to guide incentive design in value-based dental care, particularly for preventive services, such as topical fluoride application in children. We sought to assess the potential cost-effectiveness of P4P incentives for increasing topical fluoride application among children and to illustrate how simulation modelling can identify conditions under which subgroup-specific incentive levels may be optimal.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Design, setting and participants<\/jats:title>\n                    <jats:p>We developed and validated a decision-analytic microsimulation model using nationally representative data from the National Health and Nutrition Examination Survey (NHANES 2011\u20132016) to simulate a cohort of 100\u2009000 US children aged 0\u201319 years over a 10-year period starting in 2024. The model incorporated heterogeneity in demographic and clinical characteristics to estimate changes in dental caries, quality-adjusted life years (QALYs) and healthcare costs under hypothetical P4P programmes that increased topical fluoride coverage by 2.5% to 50%\u2009relative to the baseline rate of 24.5%, with incentive amounts ranging from 2.5% to 50% of provider salary. Sensitivity analyses assessed robustness to variation in key parameters.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Main outcomes<\/jats:title>\n                    <jats:p>Cumulative incidence of dental caries, QALYs, total healthcare costs and incremental cost-effectiveness ratios (ICERs).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Across a broad range of incentive\u2013coverage combinations, P4P incentives were generally cost-effective. For example, a 10% salary-based incentive linked to a 5% relative coverage increase reduced 186.3 cases of tooth decay and yielded 33.8 QALY gains per 10\u2009000 children, resulting in an ICER of $8501 per QALY gained. The intervention was estimated to be cost-saving at coverage increases \u226527.5%. Subgroup analysis indicated larger absolute benefits among racial\/ethnic minority children.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>P4P incentives to increase topical fluoride application in children could be cost-effective, and potentially cost-saving, under certain conditions. Cost-effectiveness modelling can help define incentive\u2013coverage combinations that are likely to promote both efficiency and equity. Empirical studies are needed to validate provider responsiveness and establish achievable benchmarks for programme design.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjopen-2025-111302","type":"journal-article","created":{"date-parts":[[2025,12,30]],"date-time":"2025-12-30T06:30:47Z","timestamp":1767076247000},"page":"e111302","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["Cost-effectiveness of pay-for-performance incentives for topical fluoride application among US children: a decision-analytic modelling study"],"prefix":"10.1136","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-4001-7638","authenticated-orcid":false,"given":"Sung Eun","family":"Choi","sequence":"first","affiliation":[{"name":"Department of Oral Health Policy and Epidemiology, Harvard School of Dental Medicine, Boston, Massachusetts, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Daniel","family":"Nolte","sequence":"additional","affiliation":[{"name":"Department of Oral Health Policy and Epidemiology, Harvard School of Dental Medicine, Boston, Massachusetts, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ankur","family":"Pandya","sequence":"additional","affiliation":[{"name":"Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"239","published-online":{"date-parts":[[2025,12,29]]},"reference":[{"key":"2026010703490235000_15.12.e111302.1","unstructured":"Catalyst N . What Is Pay for Performance in Healthcare. Catalyst Carryover 2018;4. doi:10.1056\/CAT.18.0245"},{"key":"2026010703490235000_15.12.e111302.2","unstructured":"The Common Wealth Fund . Value-Based Care: What It Is, and Why It\u2019s Needed, Available: https:\/\/www.commonwealthfund.org\/publications\/explainer\/2023\/feb\/value-based-care-what-it-is-why-its-needed [Accessed 1 Feb 2025]."},{"key":"2026010703490235000_15.12.e111302.3","doi-asserted-by":"publisher","DOI":"10.1186\/1472-6963-11-272"},{"key":"2026010703490235000_15.12.e111302.4","doi-asserted-by":"crossref","first-page":"1303","DOI":"10.1007\/s10198-019-01097-4","article-title":"Effects of pay-for-performance for primary care physicians on diabetes outcomes in single-payer health systems: a systematic review","volume":"20","author":"Gupta","year":"2019","journal-title":"Eur J Health Econ"},{"key":"2026010703490235000_15.12.e111302.5","doi-asserted-by":"crossref","first-page":"449","DOI":"10.1016\/j.adaj.2023.04.001","article-title":"Value-based care in dentistry: Is the future here?","volume":"154","author":"Vujicic","year":"2023","journal-title":"J Am Dent Assoc"},{"key":"2026010703490235000_15.12.e111302.6","doi-asserted-by":"crossref","first-page":"348","DOI":"10.1016\/j.adaj.2017.11.018","article-title":"Pay-for-performance incentive program in a large dental group practice","volume":"149","author":"Conrad","year":"2018","journal-title":"J Am Dent Assoc"},{"key":"2026010703490235000_15.12.e111302.7","unstructured":"Delta Dental of Massachusetts . The preventistry approach from delta dental of massachusetts is improving the oral health of our members. Available: https:\/\/deltadentalma.com\/prevention-focused\/preventistry-approach-results [Accessed 1 Feb 2025]."},{"key":"2026010703490235000_15.12.e111302.8","doi-asserted-by":"crossref","first-page":"51","DOI":"10.1111\/j.1945-1474.2009.00064.x","article-title":"Pay-for-performance in dentistry: what we know","volume":"32","author":"Voinea-Griffin","year":"2010","journal-title":"J Healthc Qual"},{"key":"2026010703490235000_15.12.e111302.9","doi-asserted-by":"crossref","first-page":"e143","DOI":"10.1016\/j.jid.2017.03.004","article-title":"Research Techniques Made Simple: Cost-Effectiveness Analysis","volume":"137","author":"Shi","year":"2017","journal-title":"Journal of Investigative Dermatology"},{"key":"2026010703490235000_15.12.e111302.10","doi-asserted-by":"crossref","DOI":"10.1161\/CIRCOUTCOMES.120.006492","article-title":"Can Pay-for Performance Incentive Levels be Determined Using a Cost-Effectiveness Framework?","volume":"13","author":"Pandya","year":"2020","journal-title":"Circ Cardiovasc Qual Outcomes"},{"key":"2026010703490235000_15.12.e111302.11","unstructured":"CDC . National Health and Nutrition Examination Survey Data, Available: https:\/\/wwwn.cdc.gov\/nchs\/nhanes\/Default.aspx [Accessed 1 May 2025]."},{"key":"2026010703490235000_15.12.e111302.12","unstructured":"Ingram DD , Makuc DM . Statistical Issues in Analyzing the NHANES Epidemiologic Follow-up Study. 2019. National Center for Health Statistics, 2013."},{"key":"2026010703490235000_15.12.e111302.13","doi-asserted-by":"publisher","DOI":"10.1111\/j.1600-0528.2008.00427.x"},{"key":"2026010703490235000_15.12.e111302.14","unstructured":"CDC . National Health and Nutrotion Examination Survey Oral Health Recorders Manual, Available: https:\/\/wwwn.cdc.gov\/nchs\/data\/nhanes\/public\/2013\/manuals\/2013-14_Oral_Health_Recorders_Procedures_Manual.pdf [Accessed 1 May 2025]."},{"key":"2026010703490235000_15.12.e111302.15","first-page":"41","article-title":"Dentoalveolar abscess among children attending a dental clinic in Nigeria","volume":"35","author":"Azodo","year":"2012","journal-title":"Odontostomatol Trop"},{"key":"2026010703490235000_15.12.e111302.16","doi-asserted-by":"crossref","first-page":"595","DOI":"10.1111\/ipd.12416","article-title":"Prevalence of early loss of primary molar and its impact in schoolchildren\u2019s quality of life","volume":"28","author":"Monte-Santo","year":"2018","journal-title":"Int J Paediatr Dent"},{"key":"2026010703490235000_15.12.e111302.17","doi-asserted-by":"publisher","DOI":"10.1001\/archpediatrics.2010.206"},{"key":"2026010703490235000_15.12.e111302.18","doi-asserted-by":"crossref","first-page":"364","DOI":"10.1016\/j.adaj.2021.01.013","article-title":"Is fluoride varnish safe?: Validating the safety of fluoride varnish","volume":"152","author":"Mascarenhas","year":"2021","journal-title":"J Am Dent Assoc"},{"key":"2026010703490235000_15.12.e111302.19","doi-asserted-by":"crossref","first-page":"89","DOI":"10.1111\/jphd.12522","article-title":"Racial and ethnic disparities in oral healthcare quality among children enrolled in Medicaid and CHIP","volume":"82 Suppl 1","author":"Herndon","year":"2022","journal-title":"J Public Health Dent"},{"key":"2026010703490235000_15.12.e111302.20","doi-asserted-by":"crossref","first-page":"646","DOI":"10.1097\/MLR.0000000000002184","article-title":"Racial Disparities in Quality of Dental Care Among Publicly Insured Children","volume":"63","author":"Choi","year":"2025","journal-title":"Med Care"},{"key":"2026010703490235000_15.12.e111302.21","unstructured":"American Dental Association . Survey of Dental Fees. 2020."},{"key":"2026010703490235000_15.12.e111302.22","doi-asserted-by":"crossref","first-page":"228","DOI":"10.1111\/jphd.12141","article-title":"Cost-effectiveness of preventing dental caries and full mouth dental reconstructions among Alaska Native children in the Yukon-Kuskokwim delta region of Alaska","volume":"76","author":"Atkins","year":"2016","journal-title":"J Public Health Dent"},{"key":"2026010703490235000_15.12.e111302.23","unstructured":"Humana . Cost of common dental procedures, Available: https:\/\/www.humana.com\/dental-insurance\/dental-resources\/cost-of-dental-procedures [Accessed 5 Jan 2025]."},{"key":"2026010703490235000_15.12.e111302.24","unstructured":"Cortigiano C . Average number of patient visits dentists have had annually since 2000, Available: https:\/\/www.beckersdental.com\/benchmarking\/average-number-of-patient-visits-dentists-have-had-annually-since-2000\/ [Accessed 10 May 2025]."},{"key":"2026010703490235000_15.12.e111302.25","unstructured":"U.S. Bureau of Labor Statistics . Occupational Outlook Handbook: Dentists.Available: https:\/\/www.bls.gov\/ooh\/healthcare\/dentists.htm [accessed 10 May 2025]."},{"key":"2026010703490235000_15.12.e111302.26","doi-asserted-by":"crossref","DOI":"10.1186\/1478-7954-2-7","article-title":"Disability weights for the burden of oral disease in South Australia","volume":"2","author":"Brennan","year":"2004","journal-title":"Popul Health Metr"},{"key":"2026010703490235000_15.12.e111302.27","unstructured":"Institute for Health Metrics and Evaluation (IHME) . Global Burden of Disease Study 2019 (GBD 2019) Disability Weights, Available: https:\/\/ghdx.healthdata.org\/record\/ihme-data\/gbd-2019-disability-weights#:~:text=Disability%20weights%2C%20which%20represent%20the,health%20and%201%20equals%20death [Accessed 2 Jan 2022]."},{"key":"2026010703490235000_15.12.e111302.28","first-page":"30","article-title":"The use of cost-utility analysis for the evaluation of caries prevention: an exploratory case study of two community-based public health interventions in a high-risk population in the UK","volume":"35","author":"Kay","year":"2018","journal-title":"Community Dent Health"},{"key":"2026010703490235000_15.12.e111302.29","unstructured":"Bureau of Labor Statistics . Consumer Price Index (CPI) Inflation Calculator, Available: http:\/\/www.bls.gov\/data\/inflation_calculator.htm [Accessed 5 Jan 2016]."},{"key":"2026010703490235000_15.12.e111302.30","doi-asserted-by":"crossref","unstructured":"Basu A . Cost-effectiveness in health and medicine . In: Estimating Costs and Valuations of Non-Health Benefits in Cost-Effectiveness Analysis. 2nd edn. 2016: 223. Available: http:\/\/www.oxfordscholarship.com\/view\/10.1093\/acprof:oso\/9780190492939.001.0001\/acprof-9780190492939","DOI":"10.1093\/acprof:oso\/9780190492939.003.0008"},{"key":"2026010703490235000_15.12.e111302.31","doi-asserted-by":"publisher","DOI":"10.1177\/0272989X12458348"},{"key":"2026010703490235000_15.12.e111302.32","doi-asserted-by":"publisher","DOI":"10.1111\/j.1524-4733.2009.00600.x"},{"key":"2026010703490235000_15.12.e111302.33","unstructured":"Orzol SFL , Laird J , Kovac M , et al . Evaluation of the Dental Transformation Initiative, Available: https:\/\/www.dhcs.ca.gov\/provgovpart\/Documents\/DTI-Evaluation-Final-Report.pdf [Accessed 5 May 2025]."},{"key":"2026010703490235000_15.12.e111302.34","doi-asserted-by":"crossref","DOI":"10.1186\/1472-6831-10-9","article-title":"Pay for performance: will dentistry follow?","volume":"10","author":"Voinea-Griffin","year":"2010","journal-title":"BMC Oral Health"},{"key":"2026010703490235000_15.12.e111302.35","doi-asserted-by":"crossref","first-page":"12","DOI":"10.1111\/cdoe.12429","article-title":"Quality measures for dental care: A systematic review","volume":"47","author":"Righolt","year":"2019","journal-title":"Community Dent Oral Epidemiol"},{"key":"2026010703490235000_15.12.e111302.36","first-page":"S95","article-title":"Advancing value in oral health through meaningful measurement","volume":"80 Suppl 2","author":"Herndon","year":"2020","journal-title":"J Public Health Dent"},{"key":"2026010703490235000_15.12.e111302.37","unstructured":"Centers for Disease Control and Prevention . CDC Scientific Statement on Community Water Fluoridation, Available: https:\/\/www.cdc.gov\/fluoridation\/about\/statement-on-the-evidence-supporting-the-safety-and-effectiveness-of-community-water-fluoridation.html [Accessed 11 Nov 2025]."},{"key":"2026010703490235000_15.12.e111302.38","unstructured":"American Dental Association . Fluoride: Topical and Systemic Supplements, Available: https:\/\/www.ada.org\/resources\/ada-library\/oral-health-topics\/fluoride-topical-and-systemic-supplements [Accessed 11 Nov 2025]."},{"key":"2026010703490235000_15.12.e111302.39","doi-asserted-by":"crossref","first-page":"506","DOI":"10.1177\/0022034520906384","article-title":"Topical Fluoride to Prevent Root Caries: Systematic Review with Network Meta-analysis","volume":"99","author":"Zhang","year":"2020","journal-title":"J Dent Res"},{"key":"2026010703490235000_15.12.e111302.40","unstructured":"Institute for Health Metrics and Evaluation . Oral disorders. 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