All ETDs from UAB

Advisory Committee Chair

Meredith Kilgore

Advisory Committee Members

Andrei Barasch

Robert S Hernandez

Patrick McNees

Haiyan Qu

Monika Safford

Document Type


Date of Award


Degree Name by School

Doctor of Philosophy (PhD) School of Health Professions


Introduction: The variability of dental care and the slow implementation of evidence-based dentistry point to the need for change. Pay for performance (P4P) programs may foster quality improvement if appropriately designed. This work demonstrates the use of modeling and simulation to evaluate such programs prior to deployment. An example is provided in the form of a P4P program for the treatment of occlusal early caries (EC) in permanent teeth. Research Design: The proposed P4P program evaluation consists of two steps. First step is to determine the optimal treatment. In this example, three non-invasive treatments (NTs), watchful-waiting (WW), sealants, and fluoride treatments were compared based on their cost-effectiveness (CE). The CE analysis used a Markov model, Monte Carlo simulations; it run over a 10-year timeframe for two different scenarios (amalgam and composite restorations). Simulations were conducted for several NT strategies: status quo, 30% or 75% increase from baseline in each NT, 100% of each NT, and 100% restoration treatment. The impact of periodontal disease, plan member disenrollment and death were accounted for. Second, the financial feasibility of the P4P was evaluated through a breakeven analysis. Results: This analysis showed that all NTs are more CE than the status quo or a 100% restoration strategy. Fluoride treatments seem to be more cost-effective than WW and sealants, although this difference is most likely not statistically significant. The relationship between strategies was dose-dependent, with 100% NT more CE than the strategies with 75% and 30% increases from the baseline. The restorative material used later in the caries treatment seem to have a larger impact on CE than NT, with amalgam more CE than composites. A P4P program aimed at increasing NT is financially feasible, although the small size of the available incentives at or below the breakeven point raises serious doubts about their ability to impact change. This example demonstrates that such a methodology can be used to evaluate P4P in dentistry. Conclusions: The proposed methodology is useful not only in evaluating the financial feasibility but also in guiding the selection of target performance areas when P4P programs are developed.