Contributions to the literature
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Research summarising the effectiveness of guideline implementation strategies remains inconclusive and lacks focus on the dental setting, which has some of the lowest rates of guideline adherence.
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Similar to findings in other settings, audit and feedback, reminders, education, patient-mediated interventions and multifaceted interventions may be effective in the dental setting, and this study identified pay for performance as an additional effective strategy.
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These findings contribute to a recognised gap in the literature, by highlighting which implementation strategies may be the most effective for dental practitioners, which can serve to inform the future adoption of clinical guidelines in this sector.
Background
Methods
Research design
Searches
Study inclusion and exclusion criteria
Population | |
Inclusion criteria | ⦁ Participants with a qualification in any dental profession. This could include dentists, specialists in endodontics, periodontics, orthodontics and special needs dentistry, dental assistants, dental therapists and dental hygienists ⦁ Participants that practiced in a clinical dental care setting |
Exclusion criteria | ⦁ Participants that follow oral- or dental-related guidelines but are not a dental practitioner, for example an ear, nose and throat surgeon or a nurse providing oral care |
Intervention | |
Inclusion criteria | ⦁ Any strategy that was utilised to facilitate the implementation of clinical guidelines into practice. These could include single interventions, which utilise a sole strategy, such as audit and feedback, education or reminders, and multifaceted interventions, which utilise multiple strategies concurrently |
Exclusion criteria | ⦁ Involved guideline dissemination as part of the intervention, meaning the comparison group or participants at baseline would not be aware of the guidelines to be able to implement them into practice |
Control | |
Inclusion criteria | ⦁ Exposure to disseminated guidelines only. Thus, participants in control groups should be aware of the existence of the guidelines, but no further intervention should be provided to facilitate their uptake |
Exclusion criteria | ⦁ No exposure to disseminated guidelines |
Outcome | |
Inclusion criteria | ⦁ Focussed on guideline adherence as a primary outcome. This could be measured by count or percentage of instances of guideline-adherent behaviour over a set time period. This could be performed prospectively using observation or retrospectively using audit or other similar methods |
Exclusion criteria | ⦁ Focussed on other outcome measures such as patient outcomes instead of guideline adherence |
Terminology
Study quality assessment
First author, year, country | Aims | Study design | Study population | EPOC categories [intervention(s)] | Comparator group | Outcome |
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Afuakwah, C., 2015, Scotland | Improve documentation of caries risk assessments (CRA) | Pretest-posttest quasi-experimental study | Four dentists working at a general dental practice in a Scottish Index of Multiple Deprivation One area | Multifaceted intervention: ⦁ Reminders [CRA pro forma, aide memoire] ⦁ Education (NFS) [staff training] | N/A | Adherence improved from 52.5% pre-intervention to 100% post-intervention |
Amemori, M., 2013, Finland | Develop and evaluate two interventions intended to increase the implementation of tobacco use prevention and cessation counselling | Cluster randomised controlled trial | 75 dentists and dental hygienists employed at 34 clinics within two municipal health care regions in Finland | ⦁ Education (meetings) [lectures, interactive sessions, multimedia demonstrations and role play session (n = 21)] ⦁ Multifaceted intervention (n = 27): o Education (meetings) [as above] o Pay for performance [fee for service] | No intervention (n = 25) | ⦁ No effect on prevention counselling for any group ⦁ Cessation counselling 6 months post-intervention was higher for intervention groups (effect size = 0.52, p = 0.007), despite a relapse after 2 months |
Bahrami, M., 2004, Scotland | Evaluate the effectiveness of different implementation strategies for clinical guidelines relating to the management of impacted and unerupted third molar teeth | Pragmatic, 2 × 2 factorial cluster randomised controlled trial | 51 general dental practices in Scotland who had been given the opportunity to attend a postgraduate course regarding the guidelines | ⦁ Reminders [computer-aided learning with decision support (n = 13)] ⦁ Audit and feedback [audit and feedback (n = 13)] ⦁ Multifaceted intervention (n = 13): o Reminders [as above] ⦁ Audit and feedback [as above] | No intervention (n = 12) | No significant difference in guideline adherence was seen between intervention and control groups |
Chopra, R., 2014, UK | To audit dentists’ antimicrobial prescription and evaluate the effectiveness of education on their adherence to antimicrobial prescribing guidelines | Pretest-posttest quasi-experimental study | Two audit cycles each including 60 patients in the dental department of a hospital in London | Education (meetings) [extensive training and education of staff and students] | N/A | A 50% increase in appropriate prescriptions was seen post intervention, as was a 38% increase in practitioners recording a diagnosis |
Elouafkaoui, P., 2016, Scotland | Compare the impact of individualised audit and feedback interventions on dentists’ antibiotic prescribing rates | Cluster randomised controlled trial | 2566 dentists from 795 general dental practices | ⦁ Audit and feedback [audit and feedback (n = 1999)] | Current practice (n = 567) | ⦁ A 5.7% greater decrease in antibiotic prescription (p = 0.01) was seen among the intervention groups ⦁ Defined daily dose rate reduced by 6.6% more in the intervention group (p = 0.03) |
Friction, J., 2011, USA | Compare the impact of two reminder approaches on access of guidelines for patients with medically complex conditions | Randomised clinical trial | 109 dentists from 15 dental clinics | ⦁ Reminders [computer alerts to providers (n = 32)] ⦁ Patient-mediated interventions [notifications to patients (n = 38)] | Usual care (n = 39) | Both interventions increased guideline website use by 19% for the first 6 months (p < 0.05); however, this was not sustained to 12 months |
Gnich, W., 2018, Scotland | Explore the effect of a financial incentive on frequency of fluoride varnish application(FVA) and underlying mechanisms | Non-equivalent groups quasi-experimental study | 709 dentists who had submitted payment claims for dental services to the NHS primary care dental contract | Pay for performance [novel fee-for-service (n = 343)] | Continuous fee-for-service (n = 350) | FVA rates increased among both groups; however, a greater increase was seen among the intervention group (β = 0.82, 95% CI = 0.72–0.92) |
Isaacson Tilliss, T., 2006, USA | To determine the effect of a multifaceted implementation strategy on oral cancer screening examinations and discussions of tobacco use | Cluster randomised controlled trial | 31 dental care providers at 6 dental practices in Colorado | Multifaceted intervention (n = 18): ⦁ Local consensus process [local consensus process] ⦁ Reminders [multi-modal reminders for practitioners] ⦁ Patient-mediated interventions [multi-modal reminders for patients] ⦁ Education (meetings) [interactive educational workshop] | Usual care (n = 12) | No significant change was seen in patient reports of dental provider practice following the intervention, except a 22.1% (p = 0.015) increase in reporting “the dentist/hygienist told me that I was being screened for oral cancer” |
Montini T., 2013, USA | To test the feasibility of using web-based computer-mediated clinical decision support system to improve dentists’ adherence to the Treating Tobacco Use and Dependence Clinical Practice Guidelines | Pretest-posttest quasi-experimental study | One general dental clinic located at the New York College of Dentistry | Reminders [computer decision support system] | N/A | ⦁ Screening patients for tobacco use increased by 33.1% (p < 0.001) ⦁ Rates of advising, referring and prescribing nicotine replacement therapy for tobacco users increased by 58.9% (p < 0.001), 15.2% (p < 0.001) and 14.3% (p = 0.035) respectively |
Rindal, D. B., 2013, USA | To determine the effect of a computer-assisted tobacco intervention tool on frequency of dentists’ adherence to tobacco guidelines | Cluster randomised controlled trial | 548 patients from 15 HealthPartners Dental Group clinics in metropolitan Minnesota | Reminders [practitioners provided with computer decision support system] | Usual care | Rates of assessing interest in quitting (17%, p = 0.0006), discussing strategies (21%, p = 0.003) and referral (20%, p = 0.007) were significantly higher in the intervention group |
Rosseel, J. P., 2012, The Netherlands | To examine the effect of patient-mediated feedback on adherence of dental practitioners to tobacco cessation guidelines | Pretest-posttest quasi-experimental study | 23 primary care dental practices in the Netherlands, their professional personnel and patients | Patient-mediated interventions [patient-mediated feedback] | N/A | More patients reported receiving assessment of smoking status (25.3% increase, p < 0.01), information on smoking (21.3% increase, p < 0.01) and advice and support (26.5%, p < 0.01) 12 months post-intervention despite a 6.1% drop in reported provision of advice after 6 months |
Shelley, D., 2011, USA | To evaluate the effect of a multicomponent intervention to implement tobacco use treatment guidelines in public health dental clinics | Pretest-posttest quasi-experimental study | 14 comprehensive care general dentistry clinics at the New York College of Dentistry | Multifaceted intervention: ⦁ Reminders [chart system] ⦁ Education (meetings) [faculty and student training] ⦁ Environment [nicotine replacement therapy] ⦁ Referral systems [referral protocol] ⦁ Audit and feedback [referral feedback] | N/A | ⦁ No significant difference in rates of screening for tobacco use ⦁ Rates of advising, assessing and referring or prescribing nicotine replacement therapy for tobacco users increased by 20.6% (p < 0.001), 12.1% (p = 0.01) and 9.1% (p = 0.01) respectively |
Simons, D., 2013, UK | To determine the effects of an audit on the process and outcomes of clinical endodontic care | Pretest-posttest quasi-experimental study | 20 clinicians within the Community Dental Service of the National Health Service | Audit and feedback [audit and feedback] | N/A | In general, there was increased adherence to various endodontic guidelines (0.7–42.9% increase), although this was not seen in all guidelines |
Walsh, M. M., 2006, USA | To compare the effects of workshop training and mailed self-study training with and without reimbursement on tobacco-use-related attitudes and behaviours as reported by dentists and patients | Cluster randomised controlled trial with a 2 × 2 factorial design | 265 dentists who participated in Delta Dental plans serving state employees in California, Pennsylvania and West Virginia | ⦁ Education (materials) [self-study (n = 100)] ⦁ Education (meetings) [workshop (n = 99)] | No intervention (n = 66) | Although patient and self-reported adherence to tobacco guidelines was higher among both intervention groups, more dentists in the workshop group reported adherence than in the self-study group. Due to a low claim rate, reimbursement had no further effect on this |
Zahabiyoun, S., 2015, UK | To determine whether clinical audit can improve use of antibiotics in the dental service | Pretest-posttest quasi-experimental study | Two dental clinics in the northeast of England | Audit and feedback [clinical audit] | N/A | ⦁ Compliance with metronidazole prescription guidelines increased by 15.3% (p = 0.012) ⦁ Compliance with amoxicillin prescription guidelines increased by 35.2% (p = 0.041) |
Type of implementation strategy | Type of outcome | Reported effects |
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Audit and feedback | Antibiotic guideline adherence | |
Endodontic guideline adherence | Some improvement†: [41] | |
Third molar guideline adherence | No improvement: [42] | |
Reminders | Tobacco cessation guideline adherence | |
Medically complex conditions guideline adherence | Significant improvement, not sustained: [45] | |
Third molar guideline adherence | No improvement: [42] | |
Education | Tobacco cessation guideline adherence | Significant improvement: [46] Some improvement: [47] |
Antibiotic guideline adherence | Improvement†: [48] | |
Patient-mediated interventions | Tobacco cessation guideline adherence | Significant improvement: [49] |
Medically complex conditions guideline adherence | Significant improvement, not sustained: [45] | |
Pay for performance | Fluoride varnish guideline adherence | Significant improvement: [50] |
Multifaceted interventions | Tobacco cessation guideline adherence | |
Caries risk assessment guideline adherence | Improvement†: [52] | |
Oral cancer screening guideline adherence | No improvement: [53] | |
Third molar guideline adherence | No improvement: [42] |
Screening
Data extraction strategy
Data synthesis and presentation
Registration
Results
Search results
Study characteristics
Quality assessment
Study identification | |||||||
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Criteria | [47] | [42] | [39] | [45] | [53] | [44] | [46] |
1. Was true randomisation used for assignment of participants to treatment groups? | Y | Y | Y | Y | ? | Y | Y |
2. Was allocation to treatment groups concealed? | Y | Y | Y | Y | N | ? | Y |
3. Were treatment groups similar at the baseline? | N | Y | N | Y | Y | Y | Y |
4. Were participants blind to treatment assignment? | N | N | N | N | N | ? | Y |
5. Were those delivering treatment blind to treatment assignment? | N | N | N | N | N | N | Y |
6. Were outcomes assessors blind to treatment assignment? | Y | Y | Y | Y | N | N | Y |
7. Were treatment groups treated identically other than the intervention of interest? | Y | Y | Y | Y | Y | Y | Y |
8. Was follow-up complete and if not, were differences between groups in terms of their follow up adequately described and analysed? | Y | Y | Y | Y | Y | Y | Y |
9. Were participants analysed in the groups to which they were randomised? | Y | Y | Y | Y | Y | Y | Y |
10. Were outcomes measured in the same way for treatment groups? | Y | Y | Y | Y | Y | Y | Y |
11. Were outcomes measured in a reliable way? | Y | Y | Y | Y | Y | Y | Y |
12. Was appropriate statistical analysis used? | Y | Y | Y | Y | N | Y | Y |
13. Was the trial design appropriate, and any deviations from the standard RCT design (individual randomisation, parallel groups) accounted for in the conduct and analysis of the trial? | Y | Y | Y | Y | N | Y | Y |
Total score | 76.9% | 76.9% | 69.2% | 92.3% | 46.2% | 69.2% | 100.0% |
Study identification | ||||||||
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Criteria | [52] | [48] | [50] | [43] | [49] | [51] | [41] | [40] |
1. Is it clear in the study what is the “cause” and what is the “effect” (i.e. there is no confusion about which variable comes first)? | Y | Y | Y | Y | Y | Y | Y | Y |
2. Were the participants included in any comparisons similar? | Y | ? | Y | ? | Y | Y | Y | Y |
3. Were the participants included in any comparisons receiving similar treatment/care, other than the exposure or intervention of interest? | Y | Y | Y | Y | Y | Y | ? | Y |
4. Was there a control group? | N | N | Y | N | N | N | N | N |
5. Were there multiple measurements of the outcome both pre and post the intervention/exposure? | Y | Y | Y | Y | Y | Y | Y | Y |
6. Was follow-up complete and if not, were differences between groups in terms of their follow-up adequately described and analysed? | Y | N/A | Y | N/A | Y | N/A | N/A | N/A |
7. Were the outcomes of participants included in any comparisons measured in the same way? | Y | Y | Y | Y | Y | Y | Y | Y |
8. Were outcomes measured in a reliable way? | ? | ? | N | N | Y | N/A | Y | N |
9. Was appropriate statistical analysis used? | N | ? | Y | Y | Y | Y | Y | Y |
Total score | 66.7% | 50.0% | 88.9% | 62.5% | 88.9% | 85.7% | 75.0% | 75.0% |