Incorporating Evidence into DH Practice-1-1

12 DEC 2007 access Overview Treatment provided by dental hygienists has a substan- tial research base, which is grounded in caries prevention, periodontal disease prevention and treatment, public health, oral health education and health promotion. A sim- ple search of the PubMed database in these areas identified over 100,000 citations. Given this wealth of scientific infor- mation, evidence-based decision making (EBDM) helps practitioners identify what is relevant so that it can be incorporated into practice. Recognizing that clinicians have time constraints and yet want to provide the best pos- sible care to their patients, an evidence-based approach offers clinicians a convenient method of finding current research to support clinical decisions; answer patient questions; and explore alter- native treatments, procedures or materials. It also requires understanding new concepts and developing new skills, which just now are beginning to be integrated into curricula and practice. EBDM skills can be difficult to acquire, and it takes time and practice to become proficient. Under- standing that busy practition- ers cannot possibly master the skills necessary to use EBDM from one short article, the following article will pro- vide: 1) an overview of EBDM concepts and skills, 2) a guide for finding the evidence and 3) a listing of online evidence- based resources that can assist in developing EBDM skills. Evidence-Based Concepts and Skills What Is Evidence-Based Decision Making? Evidence-based decision making (EBDM) is defined as the formalized process of using the skills for identifying, searching for and interpreting the results of the best scien- tific evidence, which is considered in conjunction with the clinician’s experience and judgment, the patient’s prefer- ences and values, and the clinical/patient circumstances when making patient care decisions. 1 EBDM is not unique to medicine or any specific health discipline, but represents a concise way of referring to the application of evidence to the decision-making process. The use of current best evi- dence does not replace clinical expertise or input from the patient, but rather provides another dimension to the deci- sion-making process that is also placed in context with the patient’s clinical circumstances (Figure 1). Principles of EBDM and Levels of Evidence EBDM is about solving clinical problems and involves two fundamental principles: 1. Evidence alone is never sufficient to make a clini- cal decision, as was dis- cussed in the definition of EBDM, and 2. A hierarchy of evidence exists to guide clinical decision making 2 so that the highest level of evi- dence is considered for a given question. The hierarchy of evidence is based on demonstrating that the intervention or treat- ment caused the effect and the ability to control or mini- mize bias (Figure 2). 3,4 The highest levels of evi- dence or “gold standard” for treatment questions are the systematic review and meta- analysis (synthesis of two or more randomized controlled trials [RCTs]). Also considered “level 1” evidence is an indi- vidual RCT. These are followed respectively by cohort stud- ies (level 2), case-control studies (level 3) and case reports (level 4), followed by studies not involving human subjects. 5 An excellent short graphic review of each of these research methods and designs can be found at the SUNY Downstate Medical Center, Evidence Based Medicine Course, Guide to Research Methods - The Evidence Pyramid 6 available at http://servers.medlib.hscbklyn.edu/ebm/2100.htm Systematic reviews (SRs) and meta-analyses (MAs) are considered the gold standard for evidence because of their strict protocols to reduce bias and to synthesize and ana- lyze already conducted studies that address the same question. A meta-analysis is a statistical tool commonly used with SRs, which involves combining the statistical A Practical Guide for Incorporating Evidence into Dental Hygiene Practice By Jane L. Forrest, EdD, RDH, and Syrene Miller, BA Figure 1. EBDM practice components. ©2001 Forrest, NCDHR Scientific Evidence Clinical/Patient Circumstances Experience and Judgment Patient Preferences or Values leadstory ■

data from the individual studies and conducting another analysis of the combined data. When the data are pooled from individual studies, the sample size and power usually increase. As a result, the combined effect can increase pre- cision in estimating the effects of treatment. 7 SRs and MAs facilitate decision making by providing a clear summary of the current state of the existing evidence on a specific topic. With over two million articles published annually, SRs provide a way of managing large quantities of information 3 and make it easier to keep current with new research. SRs also support the development of guidelines by putting together all that is known about a topic in an objective manner. Most recently, evidence-based (EB) methodology was used by the American Heart Association to update the “Guidelines for the Prevention of Infective Endocarditis,” 8 by the ADA for the “Guidelines on Professionally Applied Topical Fluoride: Evidence Based Clinical Recommendations” 9 and by the Canadian Dental Hygienists’ Association for its guidelines on toothbrushing and on commercially available OTC rinsing products. 10 Although they are a secondary source of information, because they synthesize already conducted research, SRs contain clear descriptions of the aims of the review, the material and methods, and a summary of the individual and combined results of the studies. 7 Systematic reviews include evidence from RCTs as well as other well-controlled methods. As valuable as SRs can be, their usefulness and the strength of the evidence derived from the SR depends on the quality of the previously published original studies (i.e., their ability to meet the eligibility requirements for inclusion in the SR). 7,11 Although each level of the hierarchy may contribute to the total body of knowledge, or a continuum of knowledge, “...not all levels are equally useful for making patient care decisions.” 4 As you progress up the pyramid, the number of studies and the amount of available literature decreases, while at the same time their relevance to answering clinical questions increases. Recognizing the level of evidence that you have is important to EB practice. EBDM Skills and the Five-Step Process EBDM requires developing new skills, such as the abili- ties to find, critically appraise and correctly apply current evidence from relevant research to decisions made in prac- tice so that what is known is reflected in the care provided. Translating these skills into action include the five steps outlined in Table I. The focus of this article, however, is on skill 2, conducting a computerized search, specifically using PubMed Clinical Queries. Distinctions Between Research and Evidence Scientific evidence is the product of well-designed and well-controlled research investigations. A single research study does not constitute “the evidence” but rather con- tributes to a body of knowledge that has been derived from multiple studies investigating the same area. 13 Thus, the body of evidence evolves over time as individual research studies are conducted, underscoring the impor- tance of staying current with the scientific literature. Once individual studies are synthesized, the evidence can help you make informed decisions about whether a method of diagnosis or a treatment/intervention is effective relative to other methods of diagnoses or to other treatment/inter- ventions and under what circumstances. Distinguishing Characteristics of EB Publications The popularity of the term “evidence-based” has result- ed in numerous articles using this phrase in their title, or in identifying it as a keyword, and yet the article does not reflect the EB process. EB publications should have a struc- tured abstract that identifies the specific objective of the study, the search strategy, selection criteria, data collection and analysis, main results and conclusions. Table II out- lines the EBDM process and how it should be reflected in an EB article. More confusion can be seen between SRs and literature reviews. Systematic reviews concentrate on answering a specific clinically focused question, making them narrower in scope than a literature review. A multidisciplinary team of experts in a given area generally conducts the review. 7 They use formal and explicit methods, and specify criteria access DEC 2007 13 Figure 2. Study types and levels of clinical evidence Randomized Controlled Trials Cohort Studies Case Control Studies Case Reports Ideas, Editorials, Opinions Animal Research In vitro (test tube) Research Meta-Analysis Systematic Reviews Based on ability to control for bias and to demonstrate cause and effect in humans 1 2 3 4 5 1. Convert information needs/problems into clinical questions so that they can be answered. 2. Conduct a computerized search with maximum efficiency for finding the best external evidence with which to answer the question. 3. Critically appraise the evidence for its validity and usefulness (clinical applicability). 4. Apply the results of the appraisal, or evidence, in clinical practice. 5. Evaluate the process and your performance. Table I. Steps Needed to Apply the EBDM Process 12

access DEC 2007 15 Guide to Research Methods, The Evidence Pyramid Critical Appraisal Skills Programme (CASP) CONSORT (Consolidated Standards of Reporting Trials) QUOROM (Quality of Reporting of Meta-Analyses) Evidence Based Decision Making, National Center for Dental Hygiene Research, Resources for Learning EBDM Skills Agency for Healthcare Research and Quality (AHRQ), Evidence Based Practice Program Centre for Evidence-Based Dentistry Centre for Evidence Based Medicine Centres for Health Evidence The Cochrane Collaboration Library PubMed- Free public version of MEDLINE SUMSearch is a "meta-search" engine for evidence-based medicine resources. Evidence-based Dentistry Journal Journal of Evidence-based Dental Practice ADA Guidelines National Guideline Clearinghouse Clinical Evidence Evidence Based On Call Evidence Watch First Consult InfoPOEMS and InfoRetriever UpToDate The Trip Database, searches over 61 sites of high-quality medical information on the web. Netting the Evidence access to helpful organizations and useful learning resources Drug Databases • Corey Nahman.com updated Daily • RxList • MEDLINEplus Health Information http://library.downstate.edu/EBM2/contents.htm http://library.downstate.edu/EBM2/2100.htm www.phru.nhs.uk/Pages/PHD/resources.htm www.consort-statement.org www.consort-statement.org/QUOROM.pdf www.usc.edu/ebnet www.usc.edu/hsc/ebnet/ebframe/ebbasics.htm www.ahrq.gov/ www.ahrq.gov/clinic/epcix.htm www.cebd.org www.cebm.net www.cche.net www.cochrane.org http://pubmed.gov http://SUMSearch.uthscsa.edu University of Texas Health Science Center at San Antonio www.nature.com/ebd/index.html www.us.elsevierhealth.com/product.jsp?isbn=15323382 www.ada.org/prof/resources/positions/statements/index.asp www.guideline.gov www.clinicalevidence.com www.eboncall.org/ evidencewatch.com/ www.firstconsult.com www.infopoems.com www.uptodate.com/ www.tripdatabase.com www.shef.ac.uk/~scharr/ir/netting www.coreynahman.com/druginfopage.html www.rxlist.com www.nlm.nih.gov/medlineplus/druginformation.html Research Design & Critical Appraisal Forms Evidence-Based Centers EB Databases and Publications Point of Care Resources

for including or excluding studies in the review, which is designed to reduce bias. The methods used to conduct a systematic review sur- pass what can reasonably be expected of any one individual. In contrast to SRs, traditional literature or narrative reviews are generally directed by an individual using personal experience to define the hypothesis or research question, and select and summa- rize the literature. The traditional approach deals with a broad range of issues on a given topic rather than answering a specific question in depth. For example, a very spe- cific question answered in a SR would be, “Is fluoride varnish more effective in preventing root caries as compared to topical SnF fluoride?” whereas a broad ques- tion in a literature review would be, “What measures are available for preventing root surface caries?” The broad review could include many types of fluorides and may not make comparisons between methods. Also, it is less systematic and more subjective, in that pre-established criteria for selecting literature are not speci- fied. 14 Finally, a literature review does not combine data or statisti- cally analyze it. A Guide for Finding the Evidence It takes time to develop the skills for identifying, searching for and interpreting the results of the best scientific evidence on your own. Sources that clinicians can begin to use immediately are PubMed Clinical Queries, the Cochrane Collaboration, and EB journals. PubMed Clinical Queries The MEDLINE database with free access through PubMed (http://pubmed.gov), gives you quick access to the literature with- out leaving your location and makes it easier to locate relevant clinical evidence 15 and keep up-to-date (Figure 3). Finding rele- vant evidence quickly is often difficult for practitioners without formal EB training. Fortunately, there is a short cut to access- ing relevant evidence. The PubMed “Clinical Queries” feature uses EB filters to quickly and effectively access relevant articles for you when you type in a main topic (Figures 4 and 5). For exam- ple, when typing “fluoride varnish” into PubMed without using the Clinical Queries feature, 470 cita- tions were identified. This then required additional steps in order to limit them to the highest levels of evidence. The results of limiting the citations identified 9 MAs and 78 RCTs. In comparison, when using the Clinical Queries Systematic Review feature, which automatically searches for system- atic reviews, meta-analyses, reviews of clinical trials, evidence- based medicine, consensus devel- opment conferences and guide- lines, 19 citations were identified (Figure 6). Six of these were full- text articles. Consequently, it is much easier and faster to review 19 abstracts than 470, and hope- fully some of the six full-text arti- cles will answer your question. If so, these could be easily down- loaded for incorporation into the clinical decision-making process. However, if you need a citation that is not full-text, it can be pur- chased online for a fee. For exam- ple, to purchase one of the identi- fied SRs, “Pit and fissure sealants versus fluoride varnishes for pre- venting dental decay in children and adolescents,” published by the Cochrane Collaboration, the fee is $25.00. For the article published in Acta Odontologica Scandinavica, “Professional fluoride varnish treatment for caries control: a systematic review of clinical trials,” the fee is $32.00. If you would like more information about PubMed and the Clinical Queries feature, access their tutorial (Figure 7) at www.nlm.nih. gov/bsd/disted/pubmed.html. The Cochrane Collaboration The Cochrane Collaboration is an international, volunteer non- profit organization comprising aca- demics, clinicians, researchers, industry representatives and journal editors who provide peer-reviewed systematic reviews that meet international standards. 16 All Cochrane Review groups have an obligation to update the review every two to four years to account for new evidence. 16 DEC 2007 access Figure 3. PubMed home page with left side navigation bar Figure 4. Clinical Queries Figure 5. Clinical Queries – Find systematic review for fluoride varnish

18 DEC 2007 access added abstracts that clearly describe the article's relevance to clinical practice and offer an understandable explanation of differences between clinical value and statistical signifi- cance. Online EBDM Resources There are several online resources for those who would like to learn more about EBDM and develop the five EBDM skills: asking good questions (the PICO process), conduct- ing computerized searches with maximum efficiency, criti- cally appraising the evidence, applying the results, and evaluating your performance of the EBDM process. Several of these resources have been mentioned in this article. Conclusion EBDM provides a strategy for improving the efficiency of integrating new evidence into patient care. Being able to search electronically across hundreds of journals at the same time for specific answers to patient questions over- comes the challenge to finding relevant clinical evidence when it’s needed to help make well-informed decisions. As EBDM becomes standard practice, individuals must be knowledgeable of what constitutes the evidence and how it is reported. Understanding EB methodology and dis- tinctions between different types of articles, such as sys- tematic reviews and literature reviews, allows the clinician to better judge the validity and relevance of reported find- ings. To assist practitioners with this endeavor, the PubMed Clinical Queries feature, Cochrane Collaboration Library and EB journals are available. By integrating good science with clinical judgment and patient preferences, clinicians enhance their decision-making ability and maximize the potential for successful patient care outcomes. References 1. Forrest JL, Miller SA. Enhancing your practice through evidence-based decision making. J Evid Base Dent Pract 2001; 1:51-7. 2. Evidence-Based Medicine Working Group. Users' guides to the med- ical literature, a manual for EB clinical practice. Chicago: AMA, 2002. 3. Long A, Harrison S. The balance of evidence. evidence-based decision making. Health Services Journal, Glaxo Wellcome supplement 1995; 6:1-2. 4. McKibbon A, Eady A, Marks S. PDQ, evidence-based principles and practice. Hamilton, Ontario: B.C. Decker Inc., 1999. 5. Oxford centre for evidence-based medicine: levels of evidence and grades of recommendations, 1998. Available at www.cebm.net/ levels_of_evidence.asp. 6. SUNY Downstate Medical Center, Medical Research Library of Brooklyn. Evidence based medicine tutorial, SUNY guide to research methods. Available at http://library.downstate.edu/EBM2/contents.htm and The evidence pyramid and research designs. Available at http:// library.downstate.edu/EBM2/2100.htm. Accessed Oct. 1, 2007. 7. Mulrow CD. Rationale for systematic reviews. BMJ. 1994; 309:597-9. 8. American Heart Association. Guidelines for the prevention of infective endocarditis. Circulation, Apr. 19, 2007. Available at http://circ.aha- journals.org/cgi/reprint/CIRCULATIONAHA.106.183095. Accessed Oct. 1, 2007. 9. American Dental Association. Professionally applied topical fluoride: evidence-based clinical recommendations. J Am Dent Assoc 2006; 137: 1151-9. 10. Asadoorian J. CDHA position paper on commercially available over- the-counter oral rinsing products. CJDH; July-August 2006 40(4):1- 13. Available online at http://cdha.ca/content/newsroom/position_ statements.asp. Accessed Oct. 2, 2007. 11. Committee on Quality of Health Care in America, IOM. Crossing the quality chasm: a new health system for the 21st century. Washington DC: The National Academy of Sciences, 2000. 12. Sackett D, Straus S, Richardson W. Evidence-based medicine: how to practice and teach EBM. London: Churchill Livingstone, 2000. 13. Greenhalgh T. "Is my practice evidence-based?" Should be answered in qualitative, as well as quantitative terms. BMJ 1996; 313:957-8. 14. Sackett D, Haynes R, Guyatt G, et al. Clinical epidemiology: a basic science for clinical medicine. 1999; Boston: Brown & Company. 15. Rosenberg W, Donald A. Evidence based medicine: an approach to clinical problem-solving. BMJ. 1995 Apr 29; 310(6987): 1122-6. Jane L. Forrest, EdD, RDH, is the chair of the Division of Health Promotion, Disease Prevention & Epidemiology, and the director of the National Center for Dental Hygiene Research at the University of Southern California School of Dentistry, Los Angeles, Calif. She has received federal funding for grants related to training faculty, clinicians and researchers. The focus of one grant was to prepare faculty on how to integrate an evidence-based approach into curriculum. As part of that grant, the Evidence-Based Decision Making Web site was established (www.usc.edu/ebnet). Dr. Forrest is an internationally recognized author and presenter on evi- dence-based decision making (EBDM). She has served as the pre- conference workshop chair for both the First and Second International Conferences on Evidence-Based Dentistry and has two chapters published on EBDM, one in the 10th edition of Clinical Periodontology and one in the 2nd edition of Dental Hygiene Concepts, Cases and Competencies . She also is the lead co-author on a new book being published, Evidence-Based Decision Making: A Translational Guide for Dental Professionals . She is active in several national and international associations and serves on several editori- al boards including the Journal of Contemporary Dental Practice , the Journal of Dental Hygiene , and as an associate editor for the Journal of Evidence-Based Dental Practice . She also is an invited peer reviewer for the Journal of Public Health Dentistry, Journal of Dental Education and Periodontology 2000 . Syrene A. Miller, BA, is involved in creating the Web site, “Evidence-Based News,” and in developing curriculum materials for Faculty Development Institutes that teach health pro- fessionals and educators how to integrate an evidence-based approach. She also is the co-author with Jane Forrest, EdD, RDH, of a new evidence-based book scheduled for issue in March 2008 titled, Evidence-based Decision-Making: A Translational Guide for Dental Professionals . Miller has presented at national and international dental, dental hygiene and allied health conferences on integrating an evidence- based approach into education, practice and research, and on enhancing dental practice and classroom presentations through the use of Internet technology and PowerPoint.