Direct and Indirect Costs per Visit for Elderly Patients and Their Caretakers Receiving Complete Dentures in Health Region 9,Thailand

Abstract

Objectives

To estimate direct and indirect costs per visit for elderly patients and their caretakers receiving complete dentures in Health Region 9, Thailand.

Method

This cross-sectional household cost analysis collected data through a structured questionnaire with 346 elderly patient–caretaker pairs at three tertiary hospitals in Health Region 9 between September 2024 and February 2025. Costs were reported as means with 95% confidence intervals estimated using the bootstrap method.

Results

The mean realized cash loss per visit was 148.23 PPP-USD (95% CI: 117.11 to 179.34). Costs explicitly attributed to patients accounted for 46.9% of the total cash losses (69.57 PPP-USD, 95% CI: 37.29 to 101.84), comprising out-of-pocket medical expenses (42.71 PPP-USD) and actual income loss (26.86 PPP-USD). Caretakers incurred 37.6% of total costs (55.76 PPP-USD, 95% CI: 53.08 to 58.44), strictly from foregone earnings driven by significant time spent at the hospital (averaging 6.3 hours per visit). Shared out-of-pocket non-medical costs, such as transportation and meals, accounted for the remaining 15.5% (22.90 PPP-USD, 95% CI: 20.33 to 25.47). Sensitivity analyses valuing unpaid time demonstrated a substantially broader economic burden.

Conclusion

Although patients bear the majority of out-of-pocket expenses for treatment, caretakers face substantial actual income loss and prolonged visit durations. Health policies supporting household expenses and the adoption of service delivery innovations to improve clinic efficiency are needed to minimize these time requirements and realized cash losses.

Keywords

out-of-pocket costs edentulous elderly complete dentures caretakers tertiary hospitals

Introduction

The percentage of the Thai population aged 65 and above is projected to reach 37.3% by 2070.^1,2 Tooth loss is a significant oral health problem among the elderly and can affect their quality of life in multiple dimensions.^3,4 This issue is increasingly relevant in Thailand as the country transitions into an aging society, making access to dental services for the elderly a crucial public health concern.⁵

Tooth loss, along with the absence of posterior occluding teeth, substantially diminishes masticatory function in older Thai individuals. Consequently, this oral health deficit frequently results in dietary restrictions, marked by a transition from high-protein foods, such as meat, to softer, carbohydrate-dense alternatives, which elevates the risk of protein-energy malnutrition and frailty.⁶ Thailand is one of the countries that have achieved remarkable success in integrating dental services into the universal health coverage (UC) scheme. This integration has significantly reduced financial barriers and increased utilization rates among the population. However, obstacles to accessing dental care for the elderly are not solely due to the cost of treatment under the UC scheme but also to non-financial barriers. Non-financial barriers include travel distance and disparities in the distribution of dentists across different areas.^7-9 Moreover, further barriers exist because complete denture treatment is not a single-visit service but requires multiple appointments.

An often-overlooked dimension of household out-of-pocket expenses and foregone earnings is caretaker costs. Among Thai elderly people, there are functional limitations requiring caretaker assistance for healthcare visits as well as during waiting times at public hospitals, which affect their caretakers’ work absence.^10,11 Elderly patients seeking dental services bear additional out-of-pocket expenses beyond government-subsidized treatment costs, particularly in cases of denture procedures, such as transportation costs to the treatment center. These expenses can be problematic, as many elderly patients have incomes below the poverty line¹² and may face high transportation costs, especially in rural areas.¹³ Additionally, the direct non-medical costs are strongly correlated with the number of visits required to the treatment center.¹⁴ There are currently no studies or reports on the direct out-of-pocket expenses and realized foregone cash earnings for elderly patients and their caretakers receiving complete dentures in Thailand. This is crucial information for understanding the limitations in accessing dental services for the elderly.

Consequently, the present study aimed to investigate the direct and indirect costs for edentulous elderly patients receiving complete dentures and for their caretakers in Health Region 9 in Thailand. This research provides important information that can support future health economics studies and the development of policy recommendations regarding the inclusion of certain costs in health funding benefit packages.

Methods

Objective

This study aimed to estimate direct and indirect costs per visit for elderly patients and their caretakers receiving complete dentures in Health Region 9, Thailand.

Study Design and Perspective

This cross-sectional household cost analysis assessed direct and indirect costs per visit for elderly patients receiving complete denture services and their accompanying caretakers. A bottom-up approach was employed to identify and measure resource use at the individual household level. The household perspective captures out-of-pocket expenses (direct medical and non-medical costs) and indirect costs arising from actual foregone cash earnings experienced by patients and caretakers. For the base-case analysis, the study focused on actual realized cash losses and did not apply a full human capital approach to value unpaid time.

Study Population

This study included elderly patients receiving complete removable dentures at tertiary hospitals in Health Region 9, Thailand, between September 2024 and February 2025, along with their accompanying primary caretakers. Primary caretakers were defined as individuals who provided support and care to elderly patients throughout the denture treatment process, including transportation to and from appointments, assistance during clinic visits, and care at home.

Inclusion and Exclusion Criteria

Eligible participants included elderly patients aged 60 years and older receiving complete removable dentures and their caretakers, provided both were able to communicate in Thai. Participants were excluded if (1) patients or caretakers were unwilling to participate in the research project, or (2) primary caretakers received financial compensation for providing care to the elderly patients.

Sample Size and Sampling Method

The sample size and sampling method were determined based on the original protocol of the parent project by Rattanachariya et al. (2025). The sample comprised 692 individuals, equally divided between 346 elderly patients receiving dentures and 346 caretakers. A multistage random sampling method was used to collect data from three tertiary hospitals (Chaiyaphum Hospital, Buriram Hospital, and Surin Hospital) in Health Region 9. The sample size was proportionally allocated among the three hospitals. Details of sample size calculations and sampling methods are described in the original protocol.¹⁵

Research Instruments and Procedures

The research instruments used in this study were interview questionnaires designed separately for elderly patients receiving complete removable dentures and for their caretakers.

Set 1: Interview questionnaire for elderly patients. This questionnaire consisted of three parts: Part 1 covered the sociodemographic characteristics of the elderly patients receiving complete dentures; Part 2 addressed the direct costs for the elderly patients, including shared direct non-medical expenses (e.g., transportation and food) for both the patient and the accompanying caretaker; Part 3 focused on the indirect costs for elderly patients. The questionnaires included open-ended sections, allowing respondents to report actual expenses and precise details.

Set 2: Interview questionnaire for elderly patients’ caretakers. This questionnaire consisted of two parts: Part 1 covered the sociodemographic characteristics of caretakers; Part 2 addressed the indirect costs. The questionnaires included open-ended sections, allowing respondents to report actual expenses and precise details.

To ensure the content validity of the instruments, the drafted questionnaires were reviewed by a panel of three experts: one expert in dental public health, one in elderly care, and one in health economics. These experts reviewed the content and provided constructive feedback. Based on their recommendations, the questionnaires were revised and refined to ensure its validity and relevance.

Cost Calculation and Valuation

Costs were reported in Thai Baht (THB) and purchasing power parity-adjusted US dollars (PPP-USD), using 2025 as the costing year. The conversion rate applied was 10.245 THB = 1 PPP-USD, based on data from the International Monetary Fund (IMF).¹⁶ PPP conversion was used because the cost basket primarily consists of non-tradable local goods and services, such as domestic transportation, local meals, indirect costs, and subsidized medical care. Unlike standard nominal exchange rates, PPP-USD accounts for the local cost of living, standardizes purchasing power, and more accurately reflects the actual financial burden on households.

To accurately reflect household production constraints and establish a clear attribution rule, the total realized household cash loss per visit was categorized into three main components: patient costs, caretaker costs, and joint household costs.

1) Patient costs consisted of direct medical costs, defined as any additional out-of-pocket medical expenses incurred beyond the scope of medical insurance coverage, and the patient’s indirect costs.

2) Caretaker costs consisted solely of the caretaker’s indirect costs.

3) Joint household costs consisted of direct non-medical costs. Because the patient and caretaker traveled together and shared meals almost entirely, estimating exact individual shares of these expenses was impractical. To avoid double counting, all shared expenses, including round-trip transportation for both individuals, accommodation, and additional food expenses beyond daily living costs during the dental visits, were classified collectively as joint household costs.

Regarding indirect costs (actual income lost), these comprised the time spent and the subsequent income lost due to the dental visits. For the elderly patients, this included the time taken to receive denture services, while for the caretakers, it included the time spent accompanying the patients to the treatment center. The valuation of these indirect costs was based directly on the actual self-reported wage deductions or foregone cash earnings experienced by both parties, rather than imputed daily minimum wages or regional average salaries. For unemployed individuals, retirees, or unpaid family members who did not incur an actual wage deduction or cash loss, their monetized lost income was recorded as zero (0 THB), adopting a strict realized cash-loss perspective. This means no shadow pricing was applied to unpaid time. Therefore, the primary results explicitly reflect actual foregone earnings and financial losses, meaning that the broader economic opportunity costs are inherently underestimated in the base-case analysis.

Sensitivity Analysis

To address the undervaluation of time for non-employed individuals in the base-case analysis, two alternative valuation scenarios were conducted. The base-case approach assigned a zero value to the time of patients and caretakers who reported no actual income loss. To reflect the broader economic opportunity cost, both scenarios replaced these zero values (0 THB) for patients and caretakers using standard economic rates, while retaining the self-reported values for those who experienced actual wage deductions.

Scenario 1 (Minimum wage valuation): Patients and caretakers reporting zero income loss were assigned the 2024 provincial daily minimum wages mandated by the Wage Committee Notification No. 12: Buriram at 345 THB (33.68 PPP-USD)/day, Surin at 344 THB (33.58 PPP-USD)/day, and Chaiyaphum at 341 THB (33.28 PPP-USD)/day. This establishes a lower-bound estimate that acknowledges the economic value of unpaid time anchored to legal minimum standards.

Scenario 2 (Average wage valuation): Patients and caretakers reporting zero income loss were assigned the average provincial daily wages derived from the 2024 Ministry of Labour report. Monthly wages were divided by 26 working days to calculate daily rates as follows: Chaiyaphum at 513 THB (50.07 PPP-USD)/day derived from 13,328 THB/month, Buriram at 507 THB (49.49 PPP-USD)/day derived from 13,160 THB/month, and Surin at 471 THB (45.97 PPP-USD)/day derived from 12,236 THB/month. This establishes an upper-bound estimate, assuming that unpaid time carries an opportunity cost equal to the local average market productivity.

All cost estimates derived from these scenarios were subsequently converted to PPP-USD to maintain comparability with the base-case results.

Ethical Approval

This research was approved by the Human Research Ethics Committee of Khon Kaen University on July 25, 2024 (Item No. 4.3.01: 22/2024, Protocol Number HE672104). Before data collection, the researcher explained the study objectives and reviewed the questionnaires' details with each participant. Sufficient time was provided for patients and caretakers to ask questions until they fully understood the study and could make an informed decision. Participants then voluntarily signed a consent form to confirm their agreement to participate. The interview process commenced only after the consent form was signed by the participants.

Data Analysis

The personal characteristics of elderly patients receiving complete removable dentures and their caretakers were used for descriptive statistical analysis. For categorical data, frequency distributions and percentages were calculated. For continuous data, the mean with the standard deviation (S.D.) or the median with minimum and maximum values was reported.

Because the cost data had a highly right-skewed distribution, where a large proportion of participants incurred zero costs, the costs were reported using both the mean with a 95% confidence interval (CI) estimated using the bootstrap method, as well as the median with minimum and maximum values. All statistical analyses were performed using Stata version 18 (StataCorp, College Station, TX, USA).

Results

1. Characteristics of the Elderly Patients Receiving Complete Dentures and Their Caretakers

Among the 346 elderly patients receiving complete dentures included in the study, the majority were female (n = 210, 60.7%). Most patients were aged between 60 and 69 years (n = 189, 54.6%), with a mean age of 68.44 years (S.D. = 6.26 years). The majority were married (n = 209, 60.4%). Most participants used the Universal Health Coverage (Gold Card) scheme (n = 214, 61.9%). The most common mode of transportation to the treatment center was by motorcycle (n = 155, 44.8%) (Table 1).

Table 1.

Characteristics of the Elderly Patients (n = 346)

Characteristics	Frequency	Percentage
Gender
Male	136	39.3
Female	210	60.7
Age (years)
60–69	189	54.6
≥ 70	157	45.4
(Mean = 68.44, S.D. = 6.26, Median = 69, Minimum = 60, Maximum = 83)
Marital status
Single	26	7.5
Married	209	60.4
Divorced/Separated	47	13.6
Widowed	64	18.5
Healthcare coverage
Government/State Enterprise Officer Benefits	120	34.7
Universal Health Coverage (Gold Card)	214	61.9
Social Security	8	2.3
Self-payment	4	1.1
Mode of transportation
Car	118	34.1
Motorcycle	155	44.8
Public bus	73	21.1

2. Characteristics of the Caretakers of the Elderly Patients

Among the 346 caretakers included in the study, the majority were female (n = 208, 60.1%). Most caretakers were aged between 40 and 49 years (n = 118, 34.1%), followed by those aged 30–39 years (n = 106, 30.6%), with an overall mean age of 39.91 years (S.D. = 9.90 years). The majority were married (n = 298, 86.1%). Regarding their relationship to the patients, most caretakers were the patients’ children (n = 219, 63.3%), followed by grandchildren (n = 100, 28.9%), and spouses (n = 23, 6.6%). Only a small percentage were siblings (n = 3, 0.9%) or others (n = 1, 0.3%), with no caretakers being neighbors (0%) (Table 2).

Table 2.

Characteristics of the Caretakers (n=346)

Characteristics	Frequency	Percentage
Gender
Male	138	39.9
Female	208	60.1
Age (years)
< 20	9	2.6
21–29	43	12.4
30–39	106	30.6
40–49	118	34.1
50–59	66	19.1
≥ 60	4	1.2
(Mean = 39.91, S.D. = 9.90, Median = 40, Minimum = 15, Maximum = 74)
Marital status
Single	35	10.1
Married	298	86.1
Divorced/Separated	10	2.9
Widowed	3	0.9
Relationship to the patient
Spouse (Husband/Wife)	23	6.6
Child	219	63.3
Grandchild	100	28.9
Sibling	3	0.9
Neighbor	0	0.0
Other	1	0.3

3. Costs for the Elderly Patients Receiving Complete Dentures and for Their Caretakers

The total realized household cash loss for complete denture treatment averaged 148.23 PPP-USD (95% CI: 117.11 to 179.34) per visit, with a median of 82.97 PPP-USD (Table 3). These realized cash losses were categorized into three components: costs explicitly attributed to patients, costs explicitly attributed to caretakers, and shared direct non-medical costs.

Table 3.

Per-Visit Costs for the Elderly Patients and Their Caretakers (in PPP-USD)

Cost component	Mean	S.D.	95% CI *	Median	Min	Max	%
1. Elderly patients (n = 346)
1.1 Direct medical costs:
Out-of-pocket medical expenses	42.71	218.91	19.80 to 65.62	0	0	3,123.48	28.8
1.2 Indirect costs: *
Actual income loss	26.86	123.62	14.32 to 38.39	0	0	976.09	18.1
Total costs of patients	69.57	303.86	37.29 to 101.84	0	0	3,123.48	46.9
2. Caretakers (n = 346)
Actual income loss^*	55.76	25.10	53.08 to 58.44	58.57	0	97.61	37.6
3. Shared direct non-medical costs (n = 346) *
(1) Transportation	15.63	15.05	13.99 to 17.27	9.76	0	78.09	10.6
(2) Additional food	7.27	11.75	5.97 to 8.57	4.88	0	78.09	4.9
(3) Accommodation	0	0	NA	0	0	0	0.0
Total shared costs	22.90	23.43	20.33 to 25.47	19.52	0	156.17	15.5
Total costs of patients and caretakers	148.23	303.92	117.11 to 179.34	82.97	3.90	3,147.90	100.0

*Estimated by a bootstrap method.

**Indirect costs represent self-reported foregone cash earnings only. Individuals not in paid employment (81.5% of patients, 8.1% of caretakers) were valued at zero.

***Shared direct non-medical costs represent joint expenses (transportation and food) incurred together by the patient and the accompanying caretaker during the visit.

Costs explicitly attributed to the elderly patients formed the largest proportion of the total realized cash loss, averaging 69.57 PPP-USD (95% CI: 37.29 to 101.84), representing 46.9% of the total costs. This component comprised direct medical costs (out-of-pocket expenses beyond healthcare coverage), averaging 42.71 PPP-USD (28.8%), and the patients' actual income loss, averaging 26.86 PPP-USD (18.1%).

For the caretakers, the financial impact was exclusively derived from actual income loss due to accompanying patients, averaging 55.76 PPP-USD (95% CI: 53.08 to 58.44) per visit. Although not the majority of the total expenses, this represented substantial foregone cash earnings, accounting for 37.6% of the total household cash losses.

Shared direct non-medical costs, representing joint out-of-pocket expenses incurred by the patient and the caretaker during the visit, averaged 22.90 PPP-USD (95% CI: 20.33 to 25.47) and accounted for the remaining 15.5% of the total costs. These shared household costs consisted of average round-trip transportation expenses of 15.63 PPP-USD (10.6%) and additional food expenses of 7.27 PPP-USD (4.9%). No accommodation expenses were reported.

Furthermore, recognizing that complete denture treatment inherently requires multiple visits, the cumulative costs over a three-month period were estimated. Including the day of data collection, the total number of visits per patient ranged from 1 to 11, with an average of 3.65 visits (SD = 1.69). Overall, 161 patients (46.5%) required 1–3 visits, while 185 patients (53.5%) required more than three visits. Most patients were accompanied by one caretaker (91.3%), whereas 8.7% had multiple caretakers (up to a maximum of five). When calculating the burden to reflect this cumulative nature, the total realized household cash losses over this period averaged 562.77 PPP-USD. Stratifying the total burden by visit frequency revealed that average household costs increased from 215.74 PPP-USD for a single visit up to 2,408.67 PPP-USD for patients requiring more than seven visits. Detailed breakdowns of these cumulative costs and stratifications are provided in the supplementary materials (Tables S1 and S2).

4. Distribution of Direct Costs

Regarding direct non-medical costs per visit, 7.8% of patients incurred no transportation costs (0 PPP-USD). The majority of patients (74.3%) spent between 0.10 and 19.52 PPP-USD. Nearly half of the patients (44.8%) had no additional food expenses, while 41.9% spent more than 4.88 PPP-USD. Notably, no accommodation costs were reported for any patient (100.0%).

Regarding direct medical costs, the distribution was highly skewed. Most patients (92.5%) reported no additional out-of-pocket medical expenses beyond their healthcare coverage, whereas only 7.5% incurred costs exceeding 67.61 PPP-USD (Table 4).

Table 4.

Direct Costs for the Elderly Patients and Caretakers (n=346)

Direct costs (in PPP-USD)	Frequency	Percentage
1. Direct non-medical costs (per visit)
1.1 Round-trip transportation
0	27	7.8
0.10 – 19.52	257	74.3
> 19.52	62	17.9
(Mean = 15.63, S.D. = 15.05, Median = 9.76, Minimum = 0, Maximum = 78.09)
1.2 Additional food expenses beyond daily living costs
0	155	44.8
0.10 – 4.88	46	13.3
> 4.88	145	41.9
(Mean = 7.27, S.D. = 11.75, Median = 4.88, Minimum = 0, Maximum = 78.09)
1.3 Accommodation
0	346	100.0
> 0	0	0.0
(Mean = 0, S.D. = 0, Median = 0, Minimum = 0, Maximum = 0)
2. Direct medical costs (per visit)
Additional out-of-pocket medical expenses beyond healthcare coverage
0 (No out-of-pocket expenses)	320	92.5
0.10 – 67.61	0	0.0
> 67.61	26	7.5
(Mean = 42.71, S.D. = 218.91, Median = 0, Minimum = 0, Maximum = 3,123.48)

5. Distribution of Indirect Costs

Regarding the indirect costs for patients, the distribution of foregone cash earnings (actual income loss) was highly skewed. The majority (81.5%) reported no income loss (0 PPP-USD) per visit. However, 11.0% lost more than 34.16 PPP-USD. For the time spent on dental visits, patients mostly required either 1–3 hours (45.4%) or 4–6 hours (46.2%) per visit, averaging 3.94 hours.

In contrast, 85.0% of caretakers experienced an income loss exceeding 34.16 PPP-USD per visit, while only 8.1% reported no income loss. Furthermore, caretakers also spent more time; 93.4% spent 4 hours or more per visit (48.3% for 4–6 hours and 45.1% for more than 6 hours), averaging 6.29 hours (Table 5).

Table 5.

Indirect Costs for the Elderly Patients and Caretakers (n = 346)

Indirect costs	Frequency	Percentage
1. Patients
1.1 Foregone cash earnings (in PPP-USD per visit)
0	282	81.5
0.10 – 34.16	26	7.5
> 34.16	38	11.0
(Mean = 26.86, S.D. = 123.62, Median = 0, Minimum = 0, Maximum = 976.09)
1.2 Time spent for dental visits (hours per visit)
1-3	157	45.4
4-6	160	46.2
> 6	29	8.4
(Mean = 3.94, S.D. = 1.67, Median = 4, Minimum = 1, Maximum = 9)
2. Caretakers
2.1 Foregone cash earnings from accompanying patients (in PPP-USD per visit)
0	28	8.1
0.10 – 34.16	24	6.9
> 34.16	294	85.0
(Mean = 55.76, S.D. = 25.10, Median = 58.57, Minimum = 0, Maximum = 97.61)
2.2 Time spent accompanying patients (hours per visit)
1-3	23	6.6
4-6	167	48.3
> 6	156	45.1
(Mean = 6.29, S.D. = 1.64, Median = 6, Minimum = 1, Maximum = 10)

6. Sensitivity Analysis of Indirect Costs

A sensitivity analysis applied two wage scenarios (Scenario 1: minimum wage; Scenario 2: average wage) to value the time of individuals reporting no income loss. For elderly patients, the mean indirect cost increased from the base case of 26.86 PPP-USD to 54.25 PPP-USD under Scenario 1 (+102.0%) and to 66.28 PPP-USD under Scenario 2 (+146.8%). For caretakers, the mean indirect cost increased slightly from 55.76 PPP-USD in the base case to 58.48 PPP-USD under Scenario 1 (+4.9%) and 59.69 PPP-USD under Scenario 2 (+7.1%). Consequently, the indirect cost ratio between caretakers and patients (C:P ratio) changed from 2.08:1 in the base case to 1.08:1 under Scenario 1 and 0.90:1 under Scenario 2 (Table 6).

Table 6.

Sensitivity Analysis of Indirect Costs for the Elderly Patients and Caretakers (n = 346)

Group	Base case Cash only		Scenario 1 Min wage		Scenario 2 Avg wage
Group	Mean	SD	Mean	SD	Mean	SD
Elderly patients (n=346)
Reported income loss (n=64)	145.19	257.35	145.19	257.35	145.19	257.35
No reported income loss (n=282)	0	0.00	33.61	0.11	48.37	1.70
Total patients	26.86	123.62	54.25	118.22	66.28	116.25
% change from base			+102.0%		+146.8%
Caretakers (n=346)
Reported income loss (n=318)	60.67	19.67	60.67	19.67	60.67	19.67
No reported income loss (n=28)	0	0.00	33.59	0.13	48.57	1.68
Total caretakers	55.76	25.10	58.48	20.25	59.69	19.15
% change from base			+4.9%		+7.1%
C:P RATIO	2.08 : 1		1.08 : 1		0.90 : 1

Discussion

The average total household realized cash losses and out-of-pocket expenses for patients and their caretakers were 148.23 PPP-USD per visit. Expenses incurred by elderly patients accounted for the largest proportion at 46.9%, followed by foregone cash earnings of caretakers at 37.6%, and shared direct non-medical costs at 15.5%. These findings are strongly influenced by Thai cultural values, particularly the filial piety that children have toward their parents. As a result, children are the primary caretakers (63.3%), who willingly sacrifice work time and actual cash earnings to accompany elderly relatives to medical appointments. However, it is important to clarify how these base-case findings should be interpreted. The primary analysis was strictly based on actual reported cash losses, assigning zero monetary value to the unpaid time of retirees and unwaged family caretakers. Therefore, the results represent only immediate realized cash losses and systematically underestimate the true economic opportunity costs or the broader household economic burden. This limitation was addressed through a sensitivity analysis applying alternative wage scenarios. When unpaid time was valued at minimum or average wages, the broader opportunity cost increased significantly. These results confirm that focusing solely on immediate cash losses obscures a substantial hidden time burden, particularly the unpaid time of elderly patients and non-working caretakers.

Regarding direct non-medical costs, average transportation costs were 15.63 PPP-USD per visit, with additional food expenses of 7.27 PPP-USD per visit. The significant burden of transportation costs, particularly for patients traveling from rural areas to advanced dental facilities, reflects the logistical challenges commonly observed in managing other chronic conditions, such as diabetes, in Thailand.¹⁷ This high travel burden is largely attributable to the limited distribution of hospitals offering specialized dental services, which forces patients to travel long distances. Furthermore, food expenses, though often overlooked, represent substantial out-of-pocket expenses due to prolonged waiting times at tertiary hospitals.^7,8,18

When comparing fundamental financial impacts of treatment, our findings on foregone earnings and non-medical costs contrast with direct cost analyses from other settings. For instance, a previous study reported indirect costs of approximately 163–202 USD for denture treatments, although their parameters differed due to international costing structures^.19 Additionally, studies in Brazil highlight that the overall budgetary impact of providing complete dentures to the elderly is projected to increase sharply by 10-30% annually.²⁰ Unlike complex chronic conditions that require extensive hospital stays, continuous long-term care, or significant home modifications,^21,22 denture visits are time-limited outpatient procedures. Consequently, costs in our study did not include accommodation or home adaptation expenses, underscoring a unique cost distribution focused primarily on the day of the visit.

In terms of productivity and time, patients spent an average of 3.94 hours per visit, resulting in mean foregone cash earnings of 26.86 PPP-USD. The meticulous and time-consuming nature of dental prosthetics, combined with a limited number of specialized dentists, contributes to extended waiting times, impacting both patients and caretakers.²³ Caretakers' foregone cash earnings alone accounted for a substantial 37.6% of total costs. Since most caretakers are working-age individuals, their absence from work leads to significantly higher foregone cash earnings compared to the elderly patients, who are often retired.^10,11,24,25

The study found that most caretakers were the patients' children (63.3%) and experienced average foregone cash earnings of 55.76 PPP-USD per visit. Although this figure appears substantial, it reflects actual full-day wage losses rather than hourly imputed values. Visiting a tertiary hospital often consumes most of a working day, especially for those travelling from rural areas, so caretakers typically forfeit an entire day’s earnings. When converted to local currency, these losses align realistically with the earnings of working-age individuals in the region, while high-income outliers further elevated the mean cost. These findings correspond with research highlighting the significant financial impact of realized cash losses when children act as primary caretakers for elderly Thais.^25,26 This is largely driven by Thai cultural values emphasizing filial piety and children’s responsibility toward their parents, combined with the limited social support systems such as community-based elderly care services.

Despite their significant economic value, caretakers' realized cash losses remain inadequately addressed in public health policies, which traditionally focus on direct clinical treatments over caretaker support.^10,25,27 Addressing this gap is critical. Unlike long-term conditions where community health volunteers can serve as co-caretakers,^28,29 specialized sporadic procedures like denture fitting shift the logistical and financial responsibilities almost entirely onto family members. Policymakers should consider interventions that mitigate these hidden structural costs, such as decentralizing advanced dental services or providing targeted support for family caretakers. Furthermore, adopting emerging service delivery innovations, such as AI-enabled ambient clinical documentation tools,³⁰ offers a promising, forward-looking strategy to improve clinic efficiency. By reducing the time required per clinic visit, healthcare facilities can directly minimize the substantial foregone cash earnings and alleviate the broader financial impact experienced by these vulnerable households.

This study has several key limitations. First, the primary analysis was conducted on a per-visit basis. Since complete denture treatment inherently requires multiple visits that vary among individuals, this per-visit focus may initially obscure the total policy-relevant financial impact. Although cumulative costs over three months were approximated in the supplementary materials to illustrate the increasing household burden with visit frequency, the study’s methodology is based on cross-sectional self-reported data rather than complete longitudinal tracking from start to finish. Second, the sample consisted solely of service users at tertiary hospitals. Therefore, the findings may not be fully generalizable to patients at primary or secondary healthcare facilities and exclude financial barriers faced by individuals unable to afford care. Third, identifying the exact contributor for certain household expenses was challenging. Joint direct non-medical expenses, such as transportation and meals, were aggregated as shared costs, which may result in incomplete capture of costs borne exclusively by patients or caretakers. Fourth, reliance on interview questionnaires for past expenses may introduce recall bias, potentially leading to over- or underestimation of actual costs. Fifth, the cost data were highly right-skewed, with many patients incurring zero out-of-pocket expenses or foregone earnings. Although medians and bootstrap confidence intervals were reported to address this skewness, mean values may still be influenced by high-income outliers among caretakers. Sixth, to reflect actual cash losses in the base-case analysis, no shadow prices were imputed for unpaid time of non-working patients or caretakers. While a sensitivity analysis explored alternative wage scenarios, the primary findings represent a strict out-of-pocket and realized cash loss perspective, potentially underestimating the broader economic opportunity cost for households. Seventh, costs were converted using a general GDP-based PPP rate. While this provides a balanced reflection of varied medical, non-medical, and wage-related costs, it may lack the precision of a healthcare-specific PPP for direct medical components. Eighth, exclusion of caretakers receiving financial compensation focuses the analysis strictly on informal family care. Although this aligns with assessing out-of-pocket and indirect household costs, it narrows generalizability and biases the sample toward familial caregiving, potentially overstating cultural interpretations of family obligations. Finally, this study adopted a household perspective and did not capture broader societal costs, such as productivity losses beyond the patient and immediate caretakers. Future research employing episode-level costing, valuing unpaid time, and applying a full societal perspective would provide a more comprehensive understanding of total economic opportunity costs.

Conclusion

The household realized cash losses and out-of-pocket expenses for complete denture treatment are primarily borne by the elderly patients themselves. Nevertheless, caretakers experience a substantial financial impact in the form of foregone cash earnings due to the prolonged duration of hospital visits. Since out-of-pocket expenses and realized cash losses for both patients and caretakers are largely driven by time spent receiving care and traveling, comprehensive health policies should consider targeted subsidies for shared non-medical costs, such as transportation.

Supplemental Material

Supplemental Material - Direct and Indirect Costs per Visit for Elderly Patients and Their Caretakers Receiving Complete Dentures in Health Region 9, Thailand

Supplemental Material for Direct and Indirect Costs per Visit for Elderly Patients and Their Caretakers Receiving Complete Dentures in Health Region 9, Thailand by Surachai Phimha, Prapassara Sirikarn, Nawaporn Rattanachariya, Chanaporn Pinsuwan, Kannika Sirichan, Norraphat Noysuwan in Health Services Insights

Supplemental Material

Supplemental Material - Direct and Indirect Costs per Visit for Elderly Patients and Their Caretakers Receiving Complete Dentures in Health Region 9, Thailand

Footnotes

Acknowledgements

The authors express their gratitude to all participants who contributed to and facilitated the data collection process. During the preparation of this work, the authors used Gemini and QuillBot to improve the English language and readability of the manuscript. After using these tools, the authors reviewed and edited the content as needed and take full responsibility for the final content of the publication.

ORCID iDs

Surachai Phimha

Prapassara Sirikarn

Author Contributions

SP, PS, and NR conceptualized and designed the study. NR collected the data, and NR and CP undertook data management. NN and KS conducted literature reviews. While the initial draft was prepared by NR and SP, the manuscript underwent substantial restructuring and critical revision by SP and PS. During the revision process, PS thoroughly re-analyzed the data and performed additional analyses. All the authors reviewed and approved the final version of the manuscript.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors confirm they have no conflicts of interest to declare.

Supplemental Material

Supplemental material for this article is available online.

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