Can the number of inappropriate orthodontic referrals be reduced by guidelines?

Key Points

• Previous research has suggested that guidelines for the referral of orthodontic patients are necessary.

• The preparation and production of referral guidelines to reflect the opinions of the referrers and secondary care providers is time consuming and labour intensive.

• The referral guidelines dissemminated by post and reinforced by follow up questionnaires did not have an effect on the proportion of inappropriate referrals made by the dentists in this study.

Abstract

Objective To develop and evaluate the effectiveness of referral guidelines for the referral of orthodontic patients to consultant and specialist practitioner orthodontists.

Design Single centre randomised controlled trial with random allocation of referral guidelines for orthodontic treatment to general dental practitioners.

Setting Hospital orthodontic departments and specialist orthodontic practices in Manchester and Stockport.

Subjects General dental practitioners and the patients they referred for orthodontic treatment.

Main outcome measure Appropriateness of referral, defined as whether the patient was accepted for orthodontic treatment.

Results The referral guidelines did not reduce the number of inappropriate referrals.

Conclusions Referral guidelines for orthodontic referrals did not influence the behaviour of the general dental practitioners. More research into the optimum methods of dissemination and implementation of referral guidelines for use in the general dental service is needed.

Comment

The effect of orthodontic referral guidelines: a randomised controlled trial K. O'Brien, J. Wright, F. Conboy, L. Bagley, D. Lewis, M. Read, R. Thompson, W. Bogues, S. Lentin, G. Parr, and B. Aron Br Dent J 2000: 188: 392–397

Nearly all patients access orthodontic treatment through their general dental practitioner who fulfils the important role of 'gatekeeper' to the orthodontic service. The decisions made in general dental practice are crucial to the use of orthodontic resources. However, all orthodontists are acutely aware of the difficulties that can arise from inappropriate referrals. If patients are referred who have little or no need for treatment, or who have poor dental health, or who are likely to decline treatment, this inflates waiting lists and delays (or even prevents) access for those with objective needs. Research has shown that a significant proportion of orthodontic referrals are inappropriate. It is often claimed that orthodontic referral guidelines offer a simple solution to this problem. The inexorable rise of the guidelines movement has been accelerated by the White Paper on the NHS and the associated consultation document on quality, A First Class Service.¹ This paper is therefore timely and the authors are to be congratulated on using a rigorous scientific approach to determine if orthodontic referral guidelines actually work. The paper also provides an insight into the lengthy systematic approach required when developing guidelines. Good intentions are necessary but, unfortunately, not sufficient for the construction of valid guidelines.

To their credit the authors have adopted the more demanding randomised controlled study design which, along with the inclusion of sufficient numbers of participants, means that we can accept their findings with a high degree of confidence. For those with an interest in assessing whether studies have sufficient 'power', examination of the 95% confidence limits confirm that this investigation can be accepted as definitive. Since this work clearly shows that orthodontic referral guidelines were not effective in reducing inappropriate referrals the challenge still remains as to how we should address this problem.