An audit and feedback intervention for reducing antibiotic prescribing in general dental practice:the RAPiD Cluster Randomised Controlled Trial

Acknowledgments: We thank the TRiaDS Research Methodology Group, including Irene Black, Debbie Bonetti, Heather Cassie, Martin Eccles, Sandra Eldridge, Jill J. Francis, Jeremy M. Grimshaw, Lorna Macpherson, Lorna McKee, Susan Michie, Nigel Pitts, Derek Richards, Douglas Stirling, Colin Tilley, Carole Torgerson, Shaun Treweek, Luke Vale, and Alan Walker for their guidance and contribution to the design and development of the study. We also thank Maria Prior for overseeing the running of the study, drafting of the published protocol, and her contribution to the design and analysis of the process evaluation. Thanks are also extended to Jill Farnham, Jenny Eades, Sarah Blackburn, and Lorna Barnsley for providing invaluable administrative support for this study. The views expressed in this article are those of the authors and may not reflect those of the funder. Funding: This study was conducted as part of the TRiaDS programme of implementation research which is funded by NHS Education for Scotland (NES). The Health Services Research Unit which is funded by the Chief Scientist Office of the Scottish Government Health and Social Care Directorates supported the study. The funder had no influence over the design, conduct, analysis and write up of the study. Data Availability: Researchers can request to access the data from the Information Services Division of NHS National Services Scotland http://www.isdscotland.org/. Some restrictions may apply for the protection of privacy and appropriate usage of the data.Peer reviewedPublisher PD

Evaluating an audit and feedback intervention for reducing antibiotic prescribing behaviour in general dental practice (the RAPiD trial): a partial factorial cluster randomised trial protocol

BACKGROUND: Antibiotic prescribing in dentistry accounts for 9% of total antibiotic prescriptions in Scottish primary care. The Scottish Dental Clinical Effectiveness Programme (SDCEP) published guidance in April 2008 (2nd edition, August 2011) for Drug Prescribing in Dentistry, which aims to assist dentists to make evidence-based antibiotic prescribing decisions. However, wide variation in prescribing persists and the overall use of antibiotics is increasing. METHODS: RAPiD is a 12-month partial factorial cluster randomised trial conducted in NHS General Dental Practices across Scotland. Its aim is to compare the effectiveness of individualised audit and feedback (A&F) strategies for the translation into practice of SDCEP recommendations on antibiotic prescribing. The trial uses routinely collected electronic healthcare data in five aspects of its design in order to: identify the study population; apply eligibility criteria; carry out stratified randomisation; generate the trial intervention; analyse trial outcomes. Eligibility was determined on contract status and a minimum level of recent NHS treatment provision. All eligible dental practices in Scotland were simultaneously randomised at baseline either to current audit practice or to an intervention group. Randomisation was stratified by single-handed/multi-handed practices. General dental practitioners (GDPs) working at intervention practices will receive individualised graphical representations of their antibiotic prescribing rate from the previous 14 months at baseline and an update at six months. GDPs could not be blinded to their practice allocation. Intervention practices were further randomised using a factorial design to receive feedback with or without: a health board comparator; a supplementary text-based intervention; additional feedback at nine months. The primary outcome is the total antibiotic prescribing rate per 100 courses of treatment over the year following delivery of the baseline intervention. A concurrent qualitative process evaluation will apply theory-based approaches using the Consolidated Framework for Implementation Research to explore the acceptability of the interventions and the Theoretical Domains Framework to identify barriers and enablers to evidence-based antibiotic prescribing behaviour by GDPs. DISCUSSION: RAPiD will provide a robust evaluation of A&F in dentistry in Scotland. It also demonstrates that linked administrative datasets have the potential to be used efficiently and effectively across all stages of an randomised controlled trial. TRIAL REGISTRATION: Current Controlled Trials ISRCTN49204710

Reducing Dental Patient's State Anxiety in General Dental Practice: A Randomized Controlled Trial

Anxiety assessment by questionnaire provides information for the dentist and may also confer a psychological benefit on patients. This study tested the hypothesis that informing dentists about patients' dental anxiety prior to commencement of treatment reduces patients' state anxiety. A randomized controlled trial was conducted involving eight General Dental Practitioners in North Wales. Participants included patients attending their first session of dental treatment, and accumulating a score of 19 or above, or scoring 5 on any one question, of the Modified Dental Anxiety Scale (MDAS). Patients (n = 119) completed Spielberger's state anxiety inventory (STAI-S) pre- and post-treatment and were randomly allocated to intervention (dentist informed of MDAS score) and control (dentist not informed) groups. Intervention patients showed greater reduction in mean change STAI-S scores (F[1, 119] = 8.74, P &lt; 0.0001). Providing the dentist with information of the high level of a patient's dental anxiety prior to treatment, and involving the patient in this, reduced the patient's state anxiety.</p

An outcome audit of the treatment of acute dentoalveolar infection: impact of penicillin resistance

OBJECTIVES: The aim of this audit was to measure the outcome of treatment of acute dentoalveolar infection and to determine if this was influenced by choice of antibiotic therapy or the presence of penicillin-resistance. SUBJECTS AND METHODS: A total of 112 patients with dentoalveolar infection were included in the audit. All patients underwent drainage, either incisional (n=105) or opening of the pulp chamber (n=7) supplemented with antibiotic therapy. A pus specimen was obtained from each patient for culture and susceptibility. Clinical signs and symptoms were recorded at the time of first presentation and re-evaluated after 48 or 72 h. RESULTS: A total of 104 (99%) of the patients who underwent incisional drainage exhibited improvement after 72 h. Signs and symptoms also improved in five of the seven patients who underwent drainage by opening of the root canal although the degree of improvement was less than that achieved by incisional drainage. Penicillin-resistant bacteria were found in 42 (38%) of the 112 patients in this study. Of the 65 patients who were given penicillin, 28 had penicillin-resistant bacteria. There was no statistical difference in the clinical outcome with regard to the antibiotic prescribed and the presence of penicillin-resistant bacteria. Strains of penicillin-resistant bacteria were isolated more frequently in patients who had previously received penicillin (p<0.05). CONCLUSION: Incisional drainage appeared to produce a more rapid improvement compared to drainage by opening of the root canal. The presence of penicillin-resistant bacteria did not adversely affect the outcome of treatment. The observations made support surgical drainage as the first principle of management and question the value of prescribing penicillin as part of treatment