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How closely do you follow best practice guidelines? Dental Health Services Victoria is keen to find out. By Sue Nelson

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How closely can—and should—you follow clinical guidelines in all situations?

Better health outcomes and increased access to good dental services are at the heart of a new pilot study into the efficacy and accessibility of the clinical practice guidelines. Dental Health Services Victoria (DHSV) has initiated the study to assess the viability of determining how closely best practice guidelines are followed.

Clinical guidelines are the most practical way to disseminate current best practice information to dentists and ensure quality and consistency in dentistry across the board. DHSV publishes clinical guidelines to help dentists provide consistent, high quality, evidence-based dental care in accordance with current literature.

“If you’re looking at it from a patient’s perspective, you’d expect that whatever treatment your dentist is insisting you undertake is consistent with the best quality practice within that profession,” says DHSV epidemiologist Dr Richard Clark, who is leading the study.

But how can that profession be confident of delivering quality outcomes, given the sheer volume of the dental literature and the need to stay informed?

“If an individual health practitioner wanted to be educated in the current research, to cover one year’s worth of interest in a specialist area or sub-specialty, they’d probably need to read for two hours every day for 80 years,” says Dr Clark. “So it’s impossible for a single person to be up with all the latest research and then to translate that into implementing best practice. A practitioner cannot undertake this on his or her own and maintain a practice at the same time.”

This is where the guidelines come in for a wide range of professions, to provide assistance to health professionals and to implement best practice consistently across the field in which the guidelines apply.

DHSV publishes a number of guidelines on its intranet—a closed external server accessible to the Victorian public dental system—but there is currently no way of knowing how these have translated directly into good practice. The study, which is in its pilot stage at the moment, aims to assess the current baseline adherence to the guidelines, and how any gaps might be addressed with a range of interventions. DHSV has engaged six dentists to review randomly selected patient records. The dentists have been trained in clinical audit techniques and will evaluate paper and electronic records to see whether there are gaps between evidence-based best practice and actual practice.

“The aim of the project is to develop a model that would facilitate undertaking clinical audits to check whether clinicians are adhering to guidelines,” says Professor Hanny Calache, director of clinical leadership education and research at DHSV.

The guidelines are not only in place to ensure the best patient outcomes—including consistent quality and safety in service delivery—but also to ensure the system runs efficiently. “We want to minimise the failure of, say, restoration of teeth, which then has to be done again,” Professor Calache says. “We need to be able to manage the disease rather than simply manage the symptoms. This would minimise the likelihood of patients coming back unnecessarily for additional visits, which has an impact on wait lists; which in turn has an impact on accessibility of the service for other patients.”

“It’s impossible for a person to be up with all the latest research and then to translate that into implementing best practice.” – Dr Richard Clark, DHSV epidemiologist

There are also instances in dentistry where patients may desire an outcome that the practitioner may not consider best practice—for example, where the use of white fillings may not be indicated, or may not be cost effective, in the dentist’s opinion. The guidelines can help to resolve an issue and, most importantly, ensure that the patient is providing informed consent.

“Evidence-based care involves having a conversation with the patient about the service you’re going to provide,” says Dr Clark. “Some patients go along with whatever is recommended, but a lot of people in the community are well-educated about health and it is important to involve them in that discussion, particularly where there are options.

“This is where the clinical guidelines come into play, because they provide the evidence for the clinician to explain the consequences of various options—and for this to be recorded in the notes. It should be recorded that the discussion has taken place and the patient made an informed decision.”

There may also be instances where a practitioner decides not to follow a guideline because there are specific circumstances that weigh against it—in this instance, good record-keeping is essential. Part of the purpose of the pilot study is to investigate how records are kept. This is a way of assessing quality of care, but can also be used to deliver the guidelines to clinicians more effectively.

“If you’re going to do a clinical audit you have to go back and read the narrative that has been written and pull out the information,” says Dr Clark. “We want to see if there’s a possibility that we can update our electronic system so that it won’t be so onerous to check, manually, every entry that every clinician has put in, using search terms.”

The study will look at how the guidelines can be made more compatible with electronic health record search criteria, to allow practitioners to search an item number at the point of care delivery and call up a list of guidelines to consider that are specific
to that procedure.

“Studies have shown that clinicians need to know information within two or three seconds; they don’t want to go away and read a book,” says Dr Clark.

There are a number of factors that might be behind a dentist not adhering to the guidelines—if dentists are not aware of them in the first place, it may be necessary for DHSV to address the dissemination process. “We make the guidelines available online, but that’s
as far as we go, so we need to develop an implementation process so that dentists are aware of the latest information,” Professor Calache says.

“We’re not selecting dentists to audit—we’re randomly selecting health records, and using a group of dentists to review the records. This is not an exercise to catch out dentists who don’t follow guidelines; it’s an exercise to check whether clinicians, as a group, show practice consistent with the guidelines.”

DHSV is also developing a process that encourages clinicians to read the guidelines online and answer a few questions—dentists can then be allocated some continuing professional development hours.

“The aim of the research is to support and, if necessary, improve professional development,” Professor Calache says. “Our purpose is also to assess our processes—how we’re actually making sure clinicians are aware of the latest evidence-based information that has come out.”

Ultimately, it’s a question of communication—ensuring that dentists understand the value of following the guidelines. “We’re looking to involve other stakeholders, like the Australian Dental Association, and consulting with the wider professional community,” says Prof Calache. “Currently we’re focusing on the public sector within a couple of sites. The next step would be to expand the number of guidelines we’re looking at, and to expand the number of public sector agencies involved. Following on from that would be a relationship with the private sector. Ideally we want to look at agreed national guidelines (for example those published by National Health and Medical Research Council or the Therapeutic Guidelines Oral and Dental) so that people going from one state to another get uniform quality of service.”

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