Toward High-Quality & Accessible Care

BY LYUBOV SLASHCHEVA, DDS, FABSCD

Healthcare providers are trained to provide the top standard of care to all patients in all circumstances. One's competency too often becomes synonymous with creating an ideal environment to provide care that meets the protocol. Many providers are thus driven to avoid circumstances in which their ability to perform a procedure is compromised. They need to ensure that one's workplace has state-of-the-art equipment, resources, and infrastructure to allow sufficient time and gear to optimize a provider's capacity to provide good care. Additionally, providers can choose which patient populations to treat, namely those who are cooperative, compliant, and may not have much disease to begin with. Which settings and patients does this kind of practice environment leave out? Those most in need of services, in safety net settings and with unique needs such as multimorbidity, frailty, or intellectual/developmental disability (IDD). As a dentist myself, I am well aware of practice management philosophies that advocate for building this kind of insulation for providers to feel like they have a successful practice. 

Fortunately for these vulnerable populations, laws have been passed to prevent overt exclusion from care access. A push for life, work, and care in the community has encouraged providers to adapt clinical care to meet the unique needs of individuals with IDD. In most disciplines, and especially evident to me in the dental profession, this has meant incorporating more sedation options for patients who "cannot tolerate the traditional treatment regimen."

Well-meaning providers routinely treat individuals with disabilities under general anesthesia, perhaps under the expectation of caregivers or assumptions of their own capacity to facilitate the behaviors necessary to accomplish treatment goals. The drivers for this include reimbursement incentives for operating room care rather than outpatient treatment that takes more time and effort. Additionally, a lack of training in behavioral assessment and management, and no formal or uniform assessment protocols or instruments for cooperation capacity or need for sedation, have encouraged a dependence or default leaning to sedative approaches to adapting clinical treatment to relieve perceived barriers to treating individuals with IDD.

This way of practice has been widely accepted for decades, with well-established specialty training programs equipping clinicians with sedation experience and funding mechanisms for favorable reimbursement. But it is to be expected that there are some major drawbacks. It is impossible to ignore the quarterly and sometimes monthly reports of patients dying while being treated under sedation. Simple procedures have turned into deadly risks. While many of these reports are of young children, the multimorbidity and frailty of individuals with IDD puts them at perhaps even greater risk for complications from repeated general anesthesia exposure. Vigilantly observing these reports and considering the hazards of the current system, the American Academy of Developmental Medicine and Dentistry (AADMD) Board of Directors asked, "what is the way forward?"

In typical interdisciplinary, patient-centered, evidence-based fervor, an ad-hoc committee from the AADMD Board formed to consider the history, best practices, and possible solutions in treatment adaptation for the clinical care of individuals with IDD. Acknowledging the myriad of ethical, legal, and clinical complexities that speckle this landscape across disciplines, the committe decided to create Guidelines on Medical and Dental Procedure Stabilization, emphasizing a single, population-focused resource for providers and patients as they make decisions about how to best extend and receive care adaptations.

The guidelines clearly state that their purpose is to promote and support appropriate use of stabilization or immobilization for per"AADMD's vision is a country in which there is parity of healthcare access and quality for people with neurodevelopmental forming high-quality and accessible diagnostic and therapeutic procedures, in ways that achieve the most optimal patient outcomes, with a safe working environment for clinical staff and the individual receiving care. With this audacious purpose, the AADMD acknowledges the proximity of the topic to issues of civil rights, human rights and liberties, and self-determination. The guideline emphasizes that these are to be respected and balanced against the benefits and risks of facilitating an excellent clinical outcome. The rationale for this balance stems from the well-documented disparities in care and health that exist for individuals with IDD and the Academy's insistence that they deserve equitable, high-quality care.

With this foundation, the Guidelines on Medical and Dental Procedure Stabilization define stabilization within the continuum of approaches from physical immobilization to pharmaceutical restraint (sedation). Indications, benefits, contraindications, and equipment are listed. Rather than detailed prescriptive protocols, the guidelines offer a set of principles and core values by which providers respect the dignity and self-determination of an individual in the context of providing high-quality care and facilitating optimal treatment outcomes. These guidelines have been disseminated through the AADMD website and networks, presented at partner organizations' conferences (such as the Special Care Dentistry Association), and are available for utilization and evaluation. AADMD's vision is a country in which there is parity of healthcare access and quality for people with neurodevelopmental disorders and intellectual disabilities throughout the lifespan. We believe that these guidelines that reaffirm historicallysound stabilization approaches contribute to this global vision.•

THE RIGHT BALANCE: The guideline emphasizes that issues of civil rights, human rights and liberties, and self-determination are to be respected and weighed against the benefits and risks of facilitating an excellent clinical outcome.

The link for the Guidelines on Medical and Dental Procedure Stabilization: aadmd.org/articles/aadmd-guidelines-medical-immobilization-and-procedural-stabilization ABOUT THE AUTHOR: Lyubov Slashcheva, DDS, FABSCD is the AADMD Board of Directors Secretary, Geriatric & Special Needs Fellow, Dental Public Health Resident, University of Iowa College of Dentistry.