Improving the quality of caries prevention

Introduction: Dental caries has long been a significant child health issue in Scotland. Significant advances have been made in recent years in tackling this issue. However, as dental caries has become less endemic to the population as a whole, it is now increasingly concentrated within a high risk segment. There are a number of effective preventive interventions that can be targeted to those at higher risk. Clinical guidelines recommend the practice of assessing an individual’s caries risk and implementing an appropriate prevention plan. Unfortunately, the translation of clinical guidelines to routine clinical practice is inconsistent throughout healthcare; including dentistry. This inconsistency results in patient receiving suboptimal care and in some cases irreversible harm. This inconsistency of practice is increasingly being identified as an unnecessary cost to the healthcare services, potentially causing patients to receiving suboptimal care and potentially irreversible harm. Therefore, efforts are being targeted at interventions that improve the consistent translation of best evidence to routine practice. Aims and Objectives Primary Aim – To improve the documentation of a caries risk assessment (CRA) for all patients attending the department of paediatric dentistry by application of a systems based approach to quality improvement methods. Secondary Aim – To investigate the impact of these quality improvement efforts on the subsequent delivery of preventive care. Materials and Methods This work was carried out with the department of Paediatric dentistry at Glasgow Dental Hospital and School over a 25 month period. Improvement of CRA was driven by the Plan-Do-Study-Act improvement method and was termed the Caries Assessment Risk Evaluation (CARE) project. This was monitored and guided by the use of a run chart, with data provided by random sampling of 5 case notes on a weekly basis. The impact that this improvement was having on preventive care delivery was monitored during the project by undertaking two retrospective surveys. These compared preventive care received by patients who did have a completed CARE tool with those who did not. At the end of the study a retrospective survey was carried out comparing the preventive care received by a random sample of patients prior to any improvement work (2007) with a random sample once the improvement work was well established (2010). Results Over the 25 months of the study there was a significant variability in the monitoring of CRA completion. In the first months of the project performance shifted to around 40%, whilst by the end of this project a shift in performance to around 80% was detected. A notable difference in the consistency of performance of completion of a CRA by the different staff groups (p < 0.001) and clinics (p = 0.04) within the department was detected. A clear impact on performance was seen when systems of working were disrupted by environmental constraints. The two surveys of preventive care received by the patients who did have a completed CARE tool in comparison to those who did not, consistently found that those patients with a completed CARE tool had more documented preventive care delivered. The 2007 versus 2010 audit found that CRA (p < 0.001), radiographs (p = 0.004), oral hygiene instruction (p < 0.001), fluoride varnish (p < 0.001), toothpaste strength (p < 0.001) and diet advice (p < 0.001) had all significantly improved following the implementation of the project. Conclusions This study found that improvement in oral health care is possible by applying a systems based approach to ensure translation of best evidence into routine practice. The greatest consistency in improvement was achieved when new processes could be integrated that complemented current working practice. The challenge remains to develop such complementary systems that are suitable for the wide variety of clinical situations that present in daily practice. The evidence from this study supports the hypothesis that improving CRA compliance leads to an improvement in documented delivery of other preventive interventions.