COMMENTARY

How Do We Determine Quality in Dental Care?

Marjorie Jeffcoat, DMD

Disclosures

July 27, 2012

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This is Dr. Marjorie Jeffcoat, coming to you from the University of Pennsylvania in Philadelphia. Some of you may have seen a recent PBS Frontline® interview that dealt with the difficulties patients experience when seeking dental care in the United States. This problem is especially profound in people who do not have a dental home -- the elderly, patients on Medicaid, patients without dental insurance, and those with limited means to pay out of pocket. The report raised a number of knotty issues. I would like to say a few words about a topic that often gets overlooked in the debate over access and cost, and that is quality.

What is quality dental care and how do we assess it? Amidst a great deal of back-and-forth in the Frontline interview, one particular exchange really jumped out at me. The interviewer asked if quality of care was delivered in a particular case in a particular clinic with a predominantly Medicaid practice. The answer was that the treatment plan matched the pretreatment radiographs. That wasn't a bad answer, but it was a partial answer. Was the treatment well done? How do you know without seeing the patient or at least obtaining some posttreatment images for comparison? It is harder to say that the treatment plan was the most appropriate for the patient given the situation, or that the plan didn't overlook a more serious situation.

The issue of quality care is an important issue, one that is going to be raised more pointedly as our healthcare system becomes increasingly managed. Quality is multifactorial. Is a crown better than an amalgam? It depends not only on the situation but also on factors such as patient age and personal preferences. In deciding what is right in an individual patient's case, expense is usually taken into consideration in the choice, but cost is not a component of quality. Cost is a secondary, independent consideration. If you pay less for a crown, is it better or is it worse? Every practitioner develops his or her individual personal vision of what constitutes quality care, and most of us try to do that every time we see a patient.

The problem comes when an organization -- whether it's a group practice, an insurance company, a healthcare corporation, or government -- needs to manage large groups of us. Organizations institute standards, audits, reviews, metrics, and spot-checks. Intelligently planned and executed, they can be reasonably effective or meaningless, self-serving, and totally incomplete. I don't have a solution to setting standards for big healthcare. However, standards for dentistry are certainly coming. Providers have a role to play in seeing that those standards are rational and relevant to real quality and don't represent some formula cooked up because it's easy to calculate. Getting it right will call for some imagination, knowledge, and creativity on the part of the dentists who are on the frontline of quality.

Meanwhile, we must continue to follow our own personal standards for quality. For me this boils down to 5 questions:

  1. Have I relieved the patient's pain appropriately?

  2. Have I successfully identified and treated any infections?

  3. Was the treatment adequate to prevent recurrence of an infection?

  4. Have I restored function with an acceptable aesthetic?

  5. Have I performed a thorough examination for the patient and not just handled the chief complaint?

Clinicians in other kinds of practices will have different lists, of course, but I try to practice in such a way that I can answer "yes" to these questions. I wonder how simple ideas like this can be managed in an increasingly impersonal healthcare setting. This deserves some serious thought. This is Dr. Marjorie Jeffcoat from the University of Pennsylvania.

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