An investigation into the implementation of clinical guidelines in the general dental services

  • Maryam Bahrami

    Student thesis: Doctoral ThesisDoctor of Philosophy


    Background: An evidence-based approach to clinical practice is advocated to improve the quality of patient care. However there is often a gap between research findings and clinical practice. To address this deficiency there is the need to assist clinicians in accessing and adopting research findings. One possible method of facilitating change in practice is clinical guidelines. It has been shown in medicine that a change in clinical practice in favour of published guidelines is dependent on an active implementation strategy. Consistently effective implementation strategies have not been identified in either medicine or dentistry. Aim: to investigate the effectiveness of different implementation strategies for evidence based guidelines, using the Scottish Intercollegiate Guidelines Network(SIGN) for appropriate removal of third molar teeth (SIGN 43, 2000).Design: a randomised-controlled trial employing a 2x2 factorial design linked to multidisciplinary evaluation. Subjects: 51 volunteer dental practices across Scotland.

    Method: Practices were randomly allocated to one of four groups. Pre-intervention data were collected from 49 dental practices. The clinical records of all 16-24 year old patients who attended the practice over a four-month period (August to December 1999) were searched by clinical researchers who were blind to the randomisation. The data extracted included the reason for their attendance and treatment received. This process was repeated following publication of the SIGN Guideline in April 2000. The postintervention phase of the project took place between June and October 2000. Data were collected from 46 practices.Interventions: Mailing of guideline (as control/non-intervention strategy), Audit and feedback (A&F); Computer-aided learning with decision support (CAL-DS), and A&F together with CAL-DS. In addition all practitioners had an opportunity to attend a postgraduate continuation education (PGCE) course on the guideline. Thus the nonintervention/control group mirrored current practice in the dissemination and implementation of the SIGN guideline in primary dental care. Outcome Measurement: The principle outcome was adherence to the guideline as assessed independently by two researchers. Any disagreement between these evaluators was discussed and an agreement reached.

    Results: The overall recruitment rate of practices was 11 % of those invited to take part(63 of 565) but this decreased to 80/0 following the intervention. Prior to the intervention the percent of patients with a problem with their third molar teeth was 70/0 compared with 220/0 after intervention. This occurred at the same time as a reduction in the overall number of patients seen by the practices (3342 compared with 1935). A statistically significant reduction in the percentage of patients treated with extraction was detected between the pre- (370/0) and post-intervention (270/0) phase of this study,(P=O.02), where this reduction was not significant for different groups (P>0.05).Compliance with the guideline was 74% of patients pre-intervention and this increased to 780/0 post-intervention. However, this difference was not statistically significant(P=0.25). The weighted t-test for audit versus no audit (P=0.62) and CAL-DS versus no CAL-DS was not significant (P=0.76). From the multilevel analysis the odds ratio of compliance with the guideline for dentists who experienced audit versus those who did not was 1.28 (95% CI 0.62 to 2.63) and this compares with an odds ratio of 0.84 (95% CI 0.88 to 1.74) for the CAL-DS dentists versus no CAL-DS. For neither was the difference statistically significant. The study was not sufficiently powered to detect an interaction effect so analyses of the main effects only were undertaken. There was however a weak correlation between pre and post cluster level compliance rates (Product Moment Correlation = -0.125, t = 0.81, n = 43, P>OA). Therefore all analyses were performed on the post intervention compliance rate. All analyses were carried out on an "intention to treat" (ITT) basis.

    Conclusion: There was no statistically significant effect of either CAL-DC or A&F on implementation of these guidelines. This study was unable to show if the CALDC and A&F independently had any effect in increasing the general dental practitioners compliance with the guideline but it may have acted as a reinforcement of the guideline messages.
    Date of Award2004
    Original languageEnglish
    SupervisorChristopher Deery (Supervisor) & Janet Clarkson (Supervisor)

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