{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,16]],"date-time":"2026-09-16T11:05:37Z","timestamp":1789556737348,"version":"build-2803163510"},"reference-count":42,"publisher":"MDPI AG","issue":"9","license":[{"start":{"date-parts":[[2026,9,9]],"date-time":"2026-09-09T00:00:00Z","timestamp":1788912000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100000133","name":"Agency for Healthcare Research and Quality","doi-asserted-by":"publisher","award":["R01HS022298"],"award-info":[{"award-number":["R01HS022298"]}],"id":[{"id":"10.13039\/100000133","id-type":"DOI","asserted-by":"publisher"}]},{"award":["R01HS022298"],"award-info":[{"award-number":["R01HS022298"]}],"id":[{"id":"https:\/\/ror.org\/03jmfdf59","id-type":"ROR","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Nurs. Rep.","Nursing Reports"],"abstract":"<jats:p>Background\/Objectives: Poor oral health, which is often overlooked in nursing homes (NHs), is associated with aspiration pneumonia. This analysis assesses the cost effectiveness of an oral hygiene intervention, \u201cMouth Care Without a Battle\u00a9\u201d (MCWB), which trains NH staff to provide daily mouth care. The first year of a pragmatic cluster randomized effectiveness trial conducted in 14 NHs demonstrated a significant reduction in pneumonia incidence in intervention NHs. Methods: Because the two-year primary outcome was not statistically significant, the first-year analysis is post hoc. The incremental cost-effectiveness ratio (ICER) of costs (staff training, time spent providing mouth care, and pneumonia-related hospitalizations) to effects (reductions in pneumonia cases) over one year was estimated using bootstrapping. Results: Analyses for 1605 residents with clustering by NH show that the likelihood that MCWB is cost-saving ranges from 6.5% to 61.1% depending on whether staff are paid benefits and various levels of estimated hospital costs. Similarly, the likelihood that MCWB results in reduced pneumonia cases but with higher costs ranges from 32.0% to 86.6%. Whether MCWB is cost-effective depends on society\u2019s willingness to pay for reduced pneumonia cases and related unmeasured benefits. These estimates may represent a lower bound of potential cost savings because analyses did not include costs of treating pneumonia if not hospitalized, ambulance transport, or the emotional costs of illness. However, other excluded costs (e.g., dental restorations) and resources required to improve fidelity could reduce the likelihood of cost savings. Conclusions: MCWB and similar interventions that improve oral health care in NHs may yield cost savings or produce benefits from the reduction in pneumonia that justify net increases in costs incurred. It is also important to consider who bears the costs (e.g., the NH) versus who reaps the benefits (e.g., healthier residents and reduced Medicare payments).<\/jats:p>","DOI":"10.3390\/nursrep16090330","type":"journal-article","created":{"date-parts":[[2026,9,9]],"date-time":"2026-09-09T14:02:48Z","timestamp":1788962568000},"page":"330","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Economic Evaluation of an Intervention to Improve Mouth Care and Reduce Pneumonia Incidence in Nursing Homes: An Exploratory Analysis"],"prefix":"10.3390","volume":"16","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-1129-0838","authenticated-orcid":false,"given":"Sally C.","family":"Stearns","sequence":"first","affiliation":[{"name":"Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA"},{"name":"The Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"conceptualization","vocabulary":"credit"},{"role":"methodology","vocabulary":"credit"},{"role":"software","vocabulary":"credit"},{"role":"validation","vocabulary":"credit"},{"role":"formal-analysis","vocabulary":"credit"},{"role":"writing-original-draft","vocabulary":"credit"},{"role":"writing-review-editing","vocabulary":"credit"},{"role":"supervision","vocabulary":"credit"},{"role":"funding-acquisition","vocabulary":"credit"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7178-2028","authenticated-orcid":false,"given":"Jane A.","family":"Weintraub","sequence":"additional","affiliation":[{"name":"Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA"},{"name":"Adams School of Dentistry, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"conceptualization","vocabulary":"credit"},{"role":"writing-original-draft","vocabulary":"credit"},{"role":"writing-review-editing","vocabulary":"credit"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7869-2057","authenticated-orcid":false,"given":"John S.","family":"Preisser","sequence":"additional","affiliation":[{"name":"Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA"},{"name":"The Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"methodology","vocabulary":"credit"},{"role":"validation","vocabulary":"credit"},{"role":"formal-analysis","vocabulary":"credit"},{"role":"writing-review-editing","vocabulary":"credit"},{"role":"supervision","vocabulary":"credit"}]},{"given":"Kimberly T.","family":"Ward","sequence":"additional","affiliation":[{"name":"The Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA"},{"name":"Duke Clinical Research Institute, Duke University, Durham, NC 27710, USA"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"writing-review-editing","vocabulary":"credit"},{"role":"validation","vocabulary":"credit"},{"role":"formal-analysis","vocabulary":"credit"},{"role":"supervision","vocabulary":"credit"}]},{"given":"Christopher J.","family":"Wretman","sequence":"additional","affiliation":[{"name":"The Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA"},{"name":"School of Social and Political Science, The University of Edinburgh, Edinburgh EH89JU, UK"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"methodology","vocabulary":"credit"},{"role":"validation","vocabulary":"credit"},{"role":"formal-analysis","vocabulary":"credit"}]},{"given":"Philip D.","family":"Sloane","sequence":"additional","affiliation":[{"name":"The Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA"},{"name":"School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"writing-review-editing","vocabulary":"credit"},{"role":"funding-acquisition","vocabulary":"credit"}]},{"given":"Sheryl","family":"Zimmerman","sequence":"additional","affiliation":[{"name":"Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA"},{"name":"The Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA"},{"name":"School of Social Work, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"conceptualization","vocabulary":"credit"},{"role":"writing-review-editing","vocabulary":"credit"},{"role":"funding-acquisition","vocabulary":"credit"}]}],"member":"1968","published-online":{"date-parts":[[2026,9,9]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","unstructured":"Bakker, M., Smit, M.J., Valentijn, A., and Visser, A. (2024). Oral health assessment in institutionalized elderly: A scoping review. BMC Oral Health, 24.","DOI":"10.1186\/s12903-024-04025-y"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"5463","DOI":"10.1038\/s41598-025-89910-4","article-title":"Oral health of nursing home residents in Flanders, Belgium, and its associated factors","volume":"15","author":"Vandenbulcke","year":"2025","journal-title":"Sci. Rep."},{"key":"ref_3","doi-asserted-by":"crossref","unstructured":"Wong, F.M.F., Ng, Y.T.Y., and Leung, W.K. (2019). Oral health and its associated factors among older institutionalized residents\u2014A systematic review. Int. J. Environ. Res. Public Health, 16.","DOI":"10.3390\/ijerph16214132"},{"key":"ref_4","unstructured":"National Institute of Health, and National Institute of Dental and Craniofacial Research (2026, September 01). Oral Health in America: Advances and Challenges, Available online: https:\/\/www.nidcr.nih.gov\/sites\/default\/files\/2021-12\/Oral-Health-in-America-Advances-and-Challenges.pdf."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"30495334261458044","DOI":"10.1177\/30495334261458044","article-title":"Oral health care for older adults: Implications for U.S. nursing homes: A structured narrative review","volume":"12","author":"Wang","year":"2026","journal-title":"Sage Open Aging"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"365","DOI":"10.1111\/ger.12357","article-title":"Randomised clinical trial: Efficacy of strategies to provide oral hygiene activities to nursing home residents with dementia who resist mouth care","volume":"35","author":"Jablonski","year":"2018","journal-title":"Gerodontology"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"110","DOI":"10.11124\/jbisrir-2015-2330","article-title":"Effectiveness of professional oral health care intervention on the oral health of residents with dementia in residential aged care facilities: A systematic review protocol","volume":"13","author":"Franks","year":"2015","journal-title":"JBI Database Syst. Rev. Implement Rep."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"795","DOI":"10.1377\/hlthaff.2022.01263","article-title":"Dementia care is widespread in US nursing homes; Facilities with the most dementia patients may offer better care","volume":"42","author":"Mukamel","year":"2023","journal-title":"Health Aff."},{"key":"ref_9","unstructured":"CDC National Center for Health Statistics (2026, August 12). Data from the National Post-Acute and Long-Term Care Study, Table 4, Available online: https:\/\/www.cdc.gov\/nchs\/npals\/webtables\/overview.htm."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"51","DOI":"10.1111\/prd.12423","article-title":"Oral health status and the etiology and prevention of nonventilator hospital-associated pneumonia","volume":"89","author":"Scannapieco","year":"2022","journal-title":"Periodontology 2000"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"54","DOI":"10.1902\/annals.2003.8.1.54","article-title":"Associations between periodontal disease and risk for nosocomial bacterial pneumonia and chronic obstructive pulmonary disease. A systematic review","volume":"8","author":"Scannapieco","year":"2003","journal-title":"Ann. Periodontol."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"81","DOI":"10.1093\/ageing\/afaa102","article-title":"Poor oral hygiene, oral microorganisms and aspiration pneumonia risk in older people in residential aged care: A systematic review","volume":"50","author":"Khadka","year":"2021","journal-title":"Age Ageing"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"164","DOI":"10.1111\/j.1600-0757.2006.00206.x","article-title":"Nursing home-associated pneumonia, hospital-acquired pneumonia and ventilator-associated pneumonia: The contribution of dental biofilms and periodontal inflammation","volume":"44","author":"Raghavendran","year":"2007","journal-title":"Periodontology 2000"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"453.e7","DOI":"10.1016\/j.jamda.2017.01.021","article-title":"Additional cost because of pneumonia in nursing home residents: Results from the incidence of pneumonia and related consequences in nursing home resident study","volume":"18","author":"Costa","year":"2017","journal-title":"J. Am. Med. Dir. Assoc."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"107","DOI":"10.1111\/ger.12386","article-title":"Cost-effectiveness of professional oral health care in Australian residential aged care facilities","volume":"36","author":"Hsueh","year":"2019","journal-title":"Gerodontology"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"1236","DOI":"10.1111\/jcpe.12775","article-title":"Professional oral health care for preventing nursing home-acquired pneumonia: A cost-effectiveness and value of information analysis","volume":"44","author":"Schwendicke","year":"2017","journal-title":"J. Clin. Periodontol."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"1465","DOI":"10.1902\/jop.2006.060010","article-title":"Systematic review of the association between respiratory diseases and oral health","volume":"77","author":"Azarpazhooh","year":"2006","journal-title":"J. Periodontol."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"2124","DOI":"10.1111\/j.1532-5415.2008.01926.x","article-title":"A systematic review of the preventive effect of oral hygiene on pneumonia and respiratory tract infection in elderly people in hospitals and nursing homes: Effect estimates and methodological quality of randomized controlled trials","volume":"56","author":"Nilsson","year":"2008","journal-title":"J. Am. Geriatr. Soc."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"46","DOI":"10.1038\/sj.ebd.6400649","article-title":"Oral hygiene in elderly people in hospitals and nursing homes","volume":"10","author":"Arpin","year":"2009","journal-title":"Evid. Based Dent."},{"key":"ref_20","first-page":"CD012416","article-title":"Oral care measures for preventing nursing home-acquired pneumonia","volume":"11","author":"Cao","year":"2022","journal-title":"Cochrane Database Syst. Rev."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"1158","DOI":"10.1111\/jgs.12317","article-title":"Effect of a person-centered mouth care intervention on care processes and outcomes in three nursing homes","volume":"61","author":"Sloane","year":"2013","journal-title":"J. Am. Geriatr. Soc."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"1086","DOI":"10.1016\/j.jamda.2018.09.036","article-title":"Improving nursing home residents\u2019 oral hygiene: Results of a cluster randomized intervention trial","volume":"19","author":"Weintraub","year":"2018","journal-title":"J. Am. Med. Dir. Assoc."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"e204321","DOI":"10.1001\/jamanetworkopen.2020.4321","article-title":"Effectiveness of a mouth care program provided by nursing home staff vs standard care on reducing pneumonia incidence: A cluster randomized trial","volume":"3","author":"Zimmerman","year":"2020","journal-title":"JAMA Netw. Open"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"878","DOI":"10.1016\/j.gerinurse.2020.06.002","article-title":"Fidelity and sustainability of Mouth Care Without a Battle and lessons for other innovations in care","volume":"41","author":"Zimmerman","year":"2020","journal-title":"Geriatr. Nurs."},{"key":"ref_25","first-page":"352","article-title":"Evidence-based health promotion in nursing homes: A pilot intervention to improve oral health","volume":"42","author":"Cadet","year":"2016","journal-title":"Educ. Gerontol."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"372","DOI":"10.1111\/scd.12577","article-title":"Cluster randomized control trial of nursing home residents\u2019 oral hygiene following the Mouth Care Matters education program for certified nursing assistants","volume":"41","author":"Hartshorn","year":"2021","journal-title":"Spec. Care Dent."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"161","DOI":"10.1016\/j.jval.2015.02.001","article-title":"Cost-effectiveness analysis alongside clinical trials II\u2014An ISPOR good research practices task force report","volume":"18","author":"Ramsey","year":"2015","journal-title":"Value Health"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"10","DOI":"10.1016\/j.jval.2021.10.008","article-title":"Consolidated Health Economic Evaluation Reporting Standards (CHEERS) 2022 explanation and elaboration: A report of the ISPOR CHEERS II Good Practices Task Force","volume":"25","author":"Husereau","year":"2022","journal-title":"Value Health"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"2680","DOI":"10.1002\/hec.4603","article-title":"A scoping review of statistical methods for trial-based economic evaluations: The current state of play","volume":"31","author":"Esser","year":"2022","journal-title":"Health Econ."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"460","DOI":"10.1177\/0272989X20916442","article-title":"Accurately reflecting uncertainty when using patient-level simulation models to extrapolate clinical trial data","volume":"40","author":"Dakin","year":"2020","journal-title":"Med. Decis. Mak."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"1447","DOI":"10.1002\/(SICI)1097-0258(19960715)15:13<1447::AID-SIM267>3.0.CO;2-V","article-title":"Estimating confidence intervals for cost-effectiveness ratios: An example from a randomized trial","volume":"15","author":"Chaudhary","year":"1996","journal-title":"Stast. Med."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"e70044","DOI":"10.1002\/asmb.70044","article-title":"Evaluating uncertainties in health economic models: A review and guide","volume":"41","author":"Chaudhary","year":"2025","journal-title":"Appl. Stoch. Model. Bus. Ind."},{"key":"ref_33","unstructured":"U.S. Bureau of Labor Statistics (2026, August 12). Occupational Employment and Wage Statistics: Licensed Practical and Licensed Vocational Nurses, Available online: https:\/\/www.bls.gov\/oes\/2019\/may\/oes292061.htm."},{"key":"ref_34","unstructured":"U.S. Bureau of Labor Statistics (2026, August 12). Occupational Employment and Wage Statistics, Available online: https:\/\/www.bls.gov\/oes\/2019\/may\/oes311131.htm."},{"key":"ref_35","unstructured":"Agency for Healthcare Research and Quality (2026, August 27). Hospital Cost and Utilization Project (HCUPnet), Available online: https:\/\/datatools.ahrq.gov\/hcupnet\/."},{"key":"ref_36","first-page":"103","article-title":"Introduction to cost-effectiveness analysis for clinicians","volume":"90","author":"Cape","year":"2013","journal-title":"Univ. Tor. Med. J."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"1101","DOI":"10.1002\/hec.2812","article-title":"Methods for covariate adjustment in cost-effectiveness analysis that use cluster randomised trials","volume":"21","author":"Gomes","year":"2012","journal-title":"Health Econ."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"416","DOI":"10.2105\/AJPH.94.3.416","article-title":"Pitfalls of and controversies in cluster randomization trials","volume":"94","author":"Donner","year":"2004","journal-title":"Am. J. Public Health"},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"81","DOI":"10.1016\/S1525-8610(04)70280-7","article-title":"The cost of treating pneumonia in the nursing home setting","volume":"4","author":"Kruse","year":"2003","journal-title":"J. Am. Med. Dir. Assoc."},{"key":"ref_40","unstructured":"Dental Quality Alliance (2021). Measuring Oral Healthcare Quality in Older Adults, American Dental Association. Available online: https:\/\/www.ada.org\/-\/media\/project\/ada-organization\/ada\/ada-org\/files\/resources\/research\/dqa\/educational-resources\/measuring_oral_healthcare_quality_in_older_adults_report."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"384","DOI":"10.1017\/ice.2022.99","article-title":"A mixed-methods evaluation of the national implementation of the Hospital-Acquired Pneumonia Prevention by Engaging Nurses (HAPPEN) initiative","volume":"44","author":"Stevenson","year":"2023","journal-title":"Infect. Control Hosp. Epidemiol."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"138","DOI":"10.1111\/j.1532-5415.2005.00565.x","article-title":"Oral care provided by certified nursing assistants in nursing homes","volume":"54","author":"Coleman","year":"2006","journal-title":"J. Am. Geriatr. 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