LETTERS TO THE EDITOR T H E JO U RN A L d ev otes th is sec tio n to co m m en t b y read ers on to p ics o f cu rre n t in terest to d en tistry . T h e ed ito r reserves th e rig h t to ed it a ll co m m u n ica tio n s to fit a v a ila b le sp a ce and req u ires that all letters b e sig ned . P rin ted co m m u n icatio n s do n ot n e c e s s a rily re flect th e o p in io n or o ffic ia l p o lic y o f th e A sso ciatio n . Y o u r p articip atio n in th is s e c tio n is in v ited .
Quality assurance □ Drs. Dem by and R osenthal are to be praised for their article on qual ity assurance (The Jo u r n a l, June). T h eir report, how ever, indicates that quality assurance in dental care is still at a fairly rudim entary level. Any system of quality assessm ent and quality assurance (two different entities) needs to do a better job of addressing: — C ost. T h e described system is im p ractical on the basis of cost, re lying as it does on a patient exam i nation in con ju n ctio n w ith each case review ed. — N onprocess in d ic a to r s o f q u a l ity. A quality assurance program m ust deal w ith factors lik e instru m ent sterilization, adequate prep aration for dealing with em ergen cies, and safety of radiography equipm ent and procedures. Q uality o f dental care cannot be assured on the b asis of dentist perform ance alone w hen “stru ctural” factors could be prom oting poor care. — In v o lv e m e n t o f th e entire d e n ta l s t a ff in th e d e v e lo p m e n t o f criteria f o r e v a lu a tio n a s w ell a s th e a c tu a l aud it procedures. T h e sug gestion that audit reports should becom e part of a p atien t’s perm a nent record is not likely to enhance the w illingness of practitioners to participate. P ossible subpoena of a record that was developed as an internal m echanism for im prove m ent of p ractice and correction of d eficien cies could be disastrous for a quality assurance program. E stablishing w ithin the dental group an internal quality assurance-audit com m ittee w ith a rotat
ing annual m em bership to do m onthly audits o f five records each would do the job w ith less disrup tion of dental office routine. Estab lish in g a purely clerical audit that w ould not perm it the filin g of any record u n til it was com plete would produce a sig n ificant sam pling of records and radiographs for each dentist— about 60 a year. A n aud it of tech n ical quality done w ith an actual patient exam i nation should be attem pted on few er patients, and should be sch ed u led at the regular recall ap pointm ent. If five patients are schedu led for an in-m outh audit each year per dentist, there would be a sufficient array o f procedures for an accep t able p ictu re of tech n ical com pe tence. If the random sam pling tech nique is specified to in clu d e the fu ll range o f procedures: a partial d en ture, a com plete denture, a cast res toration, a child patient, a periodon tal p atient, an eld erly patient, and so forth, th is fu ll range of proce dures for each dentist would be com plete. F in a lly , the role of an “ estee'med p ractition er” would be to do an an nual external audit of the integrity and thoroughness of the internal system , m uch as a dental practice has day-to-day fin an cial bookkeep ing and accounting certified by an annual external audit. JA M E S E. BO U M A N M ILW A U K EE
A u th o rs’ c o m m e n t: It is apparent from Mr. B ou m an’s letter that our goals are com patible. If he could test our audit, he w ould, we believe, read ily perceive its benefits. The
purpose of this audit was to develop an assessm ent m echanism that evaluated the te ch n ica l quality of dental services as w ell as the ju d g m ent used in developing treatm ent plans w ithin a group practice set ting. T h e audit is done tw ice a year by an external independ ent review er w hose p rin cip les of p ractice co in cid e w ith the groups to b e audited. A five-patient sam ple is audited for each dentist. T h is aud it is n ot to be construed as the entire evaluation system , nor does it review every pa tien t w hose treatm ent is com pleted in the practice. Mr. Boum an uses this approach for his own annual external audit, so we do not feel there is a real difference of opinion. A few other points prom pt com m ent: — We did not use quality assur an ce and quality assessm en t in ter changeably but used them ju d i ciously. Q uality assessm ent is de fined as the m easurem ent o f the quality of care that in clu d es the de velopm ent of the instrum ent, analysis of results, and d eterm ina tion of problem areas. Q uality as surance is defined to in clu d e both the quality assessm ent m echanism and the follow -up for correctio n of problem areas. — T his audit is neither co stly nor disruptive, becau se it is done only tw ice a year. A ctually, we have found it to be cost-effective in that a sm all sam ple yields a great deal of inform ation on the com p eten cy of dentists in tech n ical and ju d gm en tal areas. — T he audit is but one part of a com prehensive program evaluation. JADA, Vol. 97, October 1978 a 589
LETTERS
TO
THE
E D IT O R
Each center has ongoing chart au dits, yearly structural evaluations, a d etailed m anagem ent inform ation system , and fiscal analysis. T he program evaluation encom passes structure, process, and outcom e m easurem ents. — W e do not see the placem ent of the aud it in the chart as a problem in lig ht of p ossible subpoenas. N either center has experienced a subpoena in the past eight years. — Closer reading of our article, particu larly sections on pages 1009 and 10 13 , w ill show that significan t in p u t and involvem ent of th e dental staff w as obtained in the develop m ent of criteria for evaluation as w ell as in the audit procedures. We recogn ize the great im portance of provider involvem ent in th e success o f th is or any evaluation. N EA L A. D E M B Y , DMD, MPH M U R R A Y R O SEN TH A L, DDS BR O O K LYN
Putting patients to sleep □ “An approach to im proving the six-hand ed techniqu e in oral re h a b ilitatio n ” (The Jo u r n a l, June) does an ex ce lle n t service in inform ing those who do operative dental proced ures in a hospital setting. . . . However, I feel that it is detrim ental to the m any w ell-trained and qual ified dentist anesthesiologists who ad m inister general anesthesia on a daily basis in the dental office. . . . Instead of being dow ngraded, the d en tist anesthesiolog ist should be receiving accolad es for an unparal leled safety record com piled over the years. The authors say, “M any m edical and d ental anesthesiologists co n sid er the ad m inistration of general anesthesia in the dental office as a risky proced u re.” B ennett, one of th eir sources, says, how ever, “The safety o f this type of am bulatory anesthesia cannot be d en ied .” Also, “T h is p ractice (office general anes thesia) should be a com prom ise until reasonably priced outpatient anes th esia becom es available w ithin hos p ita ls.” T h e same study also reports that the NIDR estim ates th e m ortality rate for general anesthesia in dental 590 ■ JADA, Vol. 97, October 1978
offices to be 0 .0 0 0 3 % or three deaths per m illion general anesthetics. P h il lip s and Capizzi, in th e sam e book, give figures that vary from 4 0 0 to 640 deaths per m illion general anesthe tics adm inistered in hospitals to sur gical patients. . . . O f course, som e hospital patients are at higher risk, but m any are in the same physical state as the am bulatory dental pa tient. . . . T h e authors intim ate that all dental procedures should be done in the hospitals . . . . A ccording to a 1978 ADA survey, there are 1,072 h osp i tals w ith dental departm ents ap proved by the ADA. However, sin ce there are 6,5 9 2 hospitals in this cou n try, this figure represents only about 16% . O f this 16% how many can or do provide fa cilities for operative dental procedures? In the P h illip s and Capizzi article I could not find reference to com p lica tions from prolonged general anes thesia. T h ey do adm it, how ever, that “ it is evident that w ith available in form ation, d eterm ination of the role of anesthesia in operative m ortality is a d ifficu lt, if not im possible, task. Few reports encom pass enough cases to be of any sig n ifican ce beyond the realm of very special in terests.” I do not w ish to dem ean the fine services being rendered to dental pa tients in hospitals, but rather to de fend the thousands of d entists and dental anesthesiologists who ad m inister the 8 to 9 m illion general anesthetics given yearly in dental of fice s to provide the p u blic w ith safe, effective, needed, and relatively in expensive services. RO BERT
s.
RUN ZO , DMD, M E d, M S
A M ERICAN D EN TA L SO C IE T Y O F A N EST H ESIO LO G Y P IT T S B U R G H
A u th o rs’ c o m m e n t : W e generally agree that the safety record and ser v ice to the public given by w elltrained dental anesthesiologists has been outstanding and should be applauded by all circles of dentistry and m ed icine. However, we believe that w ithout the proper training, ex perience, office design, and em ergency equipm ent, such proce dures should not be done in a dental office, and we w ished to draw atten-
tio n to those situations w here anes thesia is given w ithout the proper em ergency equipm ent and w ithout trained personnel. . . . It is obvious that the safety record for office an esthetics is quite good. However, the figures from th e article by P h illip s and Capizzi should be analyzed very carefully before con clu sions are made. It cannot be de nied that three deaths per m illio n vs 4 0 0 deaths per m illion is significant. T h e 4 0 0 deaths, how ever, in clu d e all hospital procedures. If dental proce dures done in the operating room had b een separated, the data w ould have b een even m ore im pressive. A dm ittedly there are not enough h ospitals to provide this type of ser vice, but this is not a sound reason to expand this activity to the office en vironm ent, esp ecially w hen there are not enough individuals being trained. M any oral surgeons cond u ct general anesthetic procedures in an office environm ent; they have a fine record. Dr. Runzo says there are no referen ces in the literature to com p li cations resulting from prolonged general anesthetic procedures. Indi viduals who treat the m ed ically com prom ised or severely h and icap ped patient, how ever, find that post operative com plications in these pa tien ts require close supervision. One of the m ajor points to be made in th is d iscu ssion is that not every patient should be treated in the dental office. D entists should rem em ber that they are working w ith a m ed ical team and that th e m ed ical responsibility is still in the hands of the p hysician. Putting a patient to sleep is not an ordinary
Quality assurance □ Drs. Dem by and R osenthal are to be praised for their article on qual ity assurance (The Jo u r n a l, June). T h eir report, how ever, indicates that quality assurance in dental care is still at a fairly rudim entary level. Any system of quality assessm ent and quality assurance (two different entities) needs to do a better job of addressing: — C ost. T h e described system is im p ractical on the basis of cost, re lying as it does on a patient exam i nation in con ju n ctio n w ith each case review ed. — N onprocess in d ic a to r s o f q u a l ity. A quality assurance program m ust deal w ith factors lik e instru m ent sterilization, adequate prep aration for dealing with em ergen cies, and safety of radiography equipm ent and procedures. Q uality o f dental care cannot be assured on the b asis of dentist perform ance alone w hen “stru ctural” factors could be prom oting poor care. — In v o lv e m e n t o f th e entire d e n ta l s t a ff in th e d e v e lo p m e n t o f criteria f o r e v a lu a tio n a s w ell a s th e a c tu a l aud it procedures. T h e sug gestion that audit reports should becom e part of a p atien t’s perm a nent record is not likely to enhance the w illingness of practitioners to participate. P ossible subpoena of a record that was developed as an internal m echanism for im prove m ent of p ractice and correction of d eficien cies could be disastrous for a quality assurance program. E stablishing w ithin the dental group an internal quality assurance-audit com m ittee w ith a rotat
ing annual m em bership to do m onthly audits o f five records each would do the job w ith less disrup tion of dental office routine. Estab lish in g a purely clerical audit that w ould not perm it the filin g of any record u n til it was com plete would produce a sig n ificant sam pling of records and radiographs for each dentist— about 60 a year. A n aud it of tech n ical quality done w ith an actual patient exam i nation should be attem pted on few er patients, and should be sch ed u led at the regular recall ap pointm ent. If five patients are schedu led for an in-m outh audit each year per dentist, there would be a sufficient array o f procedures for an accep t able p ictu re of tech n ical com pe tence. If the random sam pling tech nique is specified to in clu d e the fu ll range o f procedures: a partial d en ture, a com plete denture, a cast res toration, a child patient, a periodon tal p atient, an eld erly patient, and so forth, th is fu ll range of proce dures for each dentist would be com plete. F in a lly , the role of an “ estee'med p ractition er” would be to do an an nual external audit of the integrity and thoroughness of the internal system , m uch as a dental practice has day-to-day fin an cial bookkeep ing and accounting certified by an annual external audit. JA M E S E. BO U M A N M ILW A U K EE
A u th o rs’ c o m m e n t: It is apparent from Mr. B ou m an’s letter that our goals are com patible. If he could test our audit, he w ould, we believe, read ily perceive its benefits. The
purpose of this audit was to develop an assessm ent m echanism that evaluated the te ch n ica l quality of dental services as w ell as the ju d g m ent used in developing treatm ent plans w ithin a group practice set ting. T h e audit is done tw ice a year by an external independ ent review er w hose p rin cip les of p ractice co in cid e w ith the groups to b e audited. A five-patient sam ple is audited for each dentist. T h is aud it is n ot to be construed as the entire evaluation system , nor does it review every pa tien t w hose treatm ent is com pleted in the practice. Mr. Boum an uses this approach for his own annual external audit, so we do not feel there is a real difference of opinion. A few other points prom pt com m ent: — We did not use quality assur an ce and quality assessm en t in ter changeably but used them ju d i ciously. Q uality assessm ent is de fined as the m easurem ent o f the quality of care that in clu d es the de velopm ent of the instrum ent, analysis of results, and d eterm ina tion of problem areas. Q uality as surance is defined to in clu d e both the quality assessm ent m echanism and the follow -up for correctio n of problem areas. — T his audit is neither co stly nor disruptive, becau se it is done only tw ice a year. A ctually, we have found it to be cost-effective in that a sm all sam ple yields a great deal of inform ation on the com p eten cy of dentists in tech n ical and ju d gm en tal areas. — T he audit is but one part of a com prehensive program evaluation. JADA, Vol. 97, October 1978 a 589
LETTERS
TO
THE
E D IT O R
Each center has ongoing chart au dits, yearly structural evaluations, a d etailed m anagem ent inform ation system , and fiscal analysis. T he program evaluation encom passes structure, process, and outcom e m easurem ents. — W e do not see the placem ent of the aud it in the chart as a problem in lig ht of p ossible subpoenas. N either center has experienced a subpoena in the past eight years. — Closer reading of our article, particu larly sections on pages 1009 and 10 13 , w ill show that significan t in p u t and involvem ent of th e dental staff w as obtained in the develop m ent of criteria for evaluation as w ell as in the audit procedures. We recogn ize the great im portance of provider involvem ent in th e success o f th is or any evaluation. N EA L A. D E M B Y , DMD, MPH M U R R A Y R O SEN TH A L, DDS BR O O K LYN
Putting patients to sleep □ “An approach to im proving the six-hand ed techniqu e in oral re h a b ilitatio n ” (The Jo u r n a l, June) does an ex ce lle n t service in inform ing those who do operative dental proced ures in a hospital setting. . . . However, I feel that it is detrim ental to the m any w ell-trained and qual ified dentist anesthesiologists who ad m inister general anesthesia on a daily basis in the dental office. . . . Instead of being dow ngraded, the d en tist anesthesiolog ist should be receiving accolad es for an unparal leled safety record com piled over the years. The authors say, “M any m edical and d ental anesthesiologists co n sid er the ad m inistration of general anesthesia in the dental office as a risky proced u re.” B ennett, one of th eir sources, says, how ever, “The safety o f this type of am bulatory anesthesia cannot be d en ied .” Also, “T h is p ractice (office general anes thesia) should be a com prom ise until reasonably priced outpatient anes th esia becom es available w ithin hos p ita ls.” T h e same study also reports that the NIDR estim ates th e m ortality rate for general anesthesia in dental 590 ■ JADA, Vol. 97, October 1978
offices to be 0 .0 0 0 3 % or three deaths per m illion general anesthetics. P h il lip s and Capizzi, in th e sam e book, give figures that vary from 4 0 0 to 640 deaths per m illion general anesthe tics adm inistered in hospitals to sur gical patients. . . . O f course, som e hospital patients are at higher risk, but m any are in the same physical state as the am bulatory dental pa tient. . . . T h e authors intim ate that all dental procedures should be done in the hospitals . . . . A ccording to a 1978 ADA survey, there are 1,072 h osp i tals w ith dental departm ents ap proved by the ADA. However, sin ce there are 6,5 9 2 hospitals in this cou n try, this figure represents only about 16% . O f this 16% how many can or do provide fa cilities for operative dental procedures? In the P h illip s and Capizzi article I could not find reference to com p lica tions from prolonged general anes thesia. T h ey do adm it, how ever, that “ it is evident that w ith available in form ation, d eterm ination of the role of anesthesia in operative m ortality is a d ifficu lt, if not im possible, task. Few reports encom pass enough cases to be of any sig n ifican ce beyond the realm of very special in terests.” I do not w ish to dem ean the fine services being rendered to dental pa tients in hospitals, but rather to de fend the thousands of d entists and dental anesthesiologists who ad m inister the 8 to 9 m illion general anesthetics given yearly in dental of fice s to provide the p u blic w ith safe, effective, needed, and relatively in expensive services. RO BERT
s.
RUN ZO , DMD, M E d, M S
A M ERICAN D EN TA L SO C IE T Y O F A N EST H ESIO LO G Y P IT T S B U R G H
A u th o rs’ c o m m e n t : W e generally agree that the safety record and ser v ice to the public given by w elltrained dental anesthesiologists has been outstanding and should be applauded by all circles of dentistry and m ed icine. However, we believe that w ithout the proper training, ex perience, office design, and em ergency equipm ent, such proce dures should not be done in a dental office, and we w ished to draw atten-
tio n to those situations w here anes thesia is given w ithout the proper em ergency equipm ent and w ithout trained personnel. . . . It is obvious that the safety record for office an esthetics is quite good. However, the figures from th e article by P h illip s and Capizzi should be analyzed very carefully before con clu sions are made. It cannot be de nied that three deaths per m illio n vs 4 0 0 deaths per m illion is significant. T h e 4 0 0 deaths, how ever, in clu d e all hospital procedures. If dental proce dures done in the operating room had b een separated, the data w ould have b een even m ore im pressive. A dm ittedly there are not enough h ospitals to provide this type of ser vice, but this is not a sound reason to expand this activity to the office en vironm ent, esp ecially w hen there are not enough individuals being trained. M any oral surgeons cond u ct general anesthetic procedures in an office environm ent; they have a fine record. Dr. Runzo says there are no referen ces in the literature to com p li cations resulting from prolonged general anesthetic procedures. Indi viduals who treat the m ed ically com prom ised or severely h and icap ped patient, how ever, find that post operative com plications in these pa tien ts require close supervision. One of the m ajor points to be made in th is d iscu ssion is that not every patient should be treated in the dental office. D entists should rem em ber that they are working w ith a m ed ical team and that th e m ed ical responsibility is still in the hands of the p hysician. Putting a patient to sleep is not an ordinary
