Key Points
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Systematic reviews of implementation trials in medicine have shown that implementation strategies are not effective under all circumstances and few studies have investigated their effectiveness in dentistry.
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There is a need to find effective and cost effective implementation strategies to optimise the integration of evidence into current dental practice.
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In this sample of Scottish general dental practitioners' adherence to the SIGN Guideline of the management of impacted and unerupted third molars was high.
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There is no simple answer to getting research evidence into practice.
Abstract
Objective To investigate the effectiveness and cost-effectiveness of different guideline implementation strategies, using the Scottish Intercollegiate Guidelines Network (SIGN) Guideline 42 'Management of unerupted and impacted third molar teeth' (published 2000) as a model.
Design A pragmatic, cluster RCT (2×2 factorial design).
Subjects Sixty-three dental practices across Scotland. Clinical records of all 16—24-year-old patients over two, four-month periods in 1999 (pre-intervention) and 2000 (post-intervention) were searched by a clinical researcher blind to the intervention group. Data were also gathered on the costs of the interventions.
Interventions Group 1 received a copy of SIGN 42 Guideline and had an opportunity to attend a postgraduate education course (PGEC). In addition to this, group 2 received audit and feedback (A and F). Group 3 received a computer aided learning (CAL) package. Group 4 received A and F and CAL.
Principal outcome measurement The proportion of patients whose treatment complied with the guideline.
Results The weighted t-test for A and F versus no A and F (P=0.62) and CAL versus no CAL (P=0.76) were not statistically significant. Given the effectiveness results (no difference) the cost effectiveness calculation became a cost-minimisation calculation. The minimum cost intervention in the trial consisted of providing general dental practitioners (GDPs) with guidelines and the option of attending PGEC courses. Routine data which subsequently became available showed a Scotland-wide fall in extractions prior to data collection.
Conclusion In an environment in which pre-intervention compliance was unexpectedly high, neither CAL nor A and F increased the dentists' compliance with the SIGN guideline compared with mailing of the guideline and the opportunity to attend a postgraduate course. The cost of the CAL arm of the trial was greater than the A and F arm. Further work is required to understand dental professionals' behaviour in response to guideline implementation strategies.
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Acknowledgements
The authors would like to thank:
Professor Graham Ogden, Dundee Dental Hospital and School, University of Dundee, for help with the development of the CAL Package and the postgraduate courses.
For additional statistical advice, Marion Campbell of the Health Services Research Unit (HSRU), University of Aberdeen.
Professor Jeremy Grimshaw, Ottawa Health Research Institute, Canada (formerly HSRU) and Professor Trevor Sheldon, University of York for methodological advice.
Elaine Humphries, Audit Facilitator, NHS Education for Scotland for her support and Dr James Rennie Dental Director of NHS Education Scotland for his intellectual input into the study.
The following General Dental Practitioners assisted with the development of the CAL package. Dr Iain Hunter, Dr Andrew Wright, Dr Jim McCafferty, Dr Colin Yule.
We would also like to thank everyone involved in the study, particularly Marilyn Laird, jenny Johnson, Louise Cardno and the participating dental practices.
This project was supported by Scottish Executive's Chief Scientists Office and NHS R&D Programme (Trial R2-64). The Dental Health Services Research Unit is core funded by the Chief Scientist Office of the Scottish Executive Health Department. The views expressed are those of the authors.
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Bahrami, M., Deery, C., Clarkson, J. et al. Effectiveness of strategies to disseminate and implement clinical guidelines for the management of impacted and unerupted third molars in primary dental care, a cluster randomised controlled trial. Br Dent J 197, 691–696 (2004). https://doi.org/10.1038/sj.bdj.4811858
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DOI: https://doi.org/10.1038/sj.bdj.4811858
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