{
  "abstract": "Objective 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.Design, setting and participants We developed and validated a decision-analytic microsimulation model using nationally representative data from the National Health and Nutrition Examination Survey (NHANES 2011–2016) to simulate a cohort of 100 000 US children aged 0–19 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% relative 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.Main outcomes Cumulative incidence of dental caries, QALYs, total healthcare costs and incremental cost-effectiveness ratios (ICERs).Results Across a broad range of incentive–coverage 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 10 000 children, resulting in an ICER of $8501 per QALY gained. The intervention was estimated to be cost-saving at coverage increases ≥27.5%. Subgroup analysis indicated larger absolute benefits among racial/ethnic minority children.Conclusion 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–coverage 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.",
  "authors": [
    {
      "affiliations": [
        "Department of Oral Health Policy and Epidemiology, Harvard School of Dental Medicine, Boston, Massachusetts, USA"
      ],
      "name": "Sung Eun Choi"
    },
    {
      "affiliations": [
        "Department of Oral Health Policy and Epidemiology, Harvard School of Dental Medicine, Boston, Massachusetts, USA"
      ],
      "name": "Daniel Nolte"
    },
    {
      "affiliations": [
        "Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA"
      ],
      "name": "Ankur Pandya"
    }
  ],
  "title": "Cost-effectiveness of pay-for-performance incentives for topical fluoride application among US children: a decision-analytic modelling study",
  "uid": "0142afaa-9685-5f02-ac87-e8ebd54d2660"
}