Presentation is loading. Please wait.

Presentation is loading. Please wait.

TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 1 Evidence-based Dental Practice Developing guidelines or clinical recommendations.

Similar presentations


Presentation on theme: "TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 1 Evidence-based Dental Practice Developing guidelines or clinical recommendations."— Presentation transcript:

1 TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 1 Evidence-based Dental Practice Developing guidelines or clinical recommendations

2 TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 2 Outline The practice of EBD at a community health center –Define clinical questions –Locate and critique systematic reviews –If no reviews are available, locate and critique primary research –Develop clinical protocols –Implement the protocols in practice

3 TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 3 What is EBD practice? [EBD] is a set of principles and methods intended to ensure that, to the greatest extent possible, medical [dental] decisions, guidelines, and other types of policies are based on and consistent with good evidence of effectiveness and benefit. Eddy M. Health Affairs 2005:24:9-17

4 TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 4 EBD Practice at a Community Health Center Step 1: Identify procedures that require standardization or reduction in variability –Review of procedures provided, word-of- mouth –Review of cost variation –Review of charts –Determine the benefits and harms of different approaches

5 TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 5 EBD Practice at a Community Health Center Step 2: Share the data with the practitioners (dentists and dental hygienists) and decide on the need for developing clinical protocols (guidelines), or standards –Guidelines are statements that should be followed, but can be adapted based on patients needs and conditions. –Clinical protocols define in steps how guidelines are implemented in clinical care. –Standards: are statements and policies that must be followed without modification.

6 TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 6 EBD Practice at a Community Health Center Step 2: Form a committee to steer the process –Representatives from different groups (dentists, hygienists, medical and allied health) –Content consultants from dental schools –Other consultants Methods Search for evidence EBD experts

7 TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 7 EBD Practice at a Community Health Center Step 3: Decide on the clinical question(s) which, if answered, can resolve the clinical issue defined in the first step. Use a modified PICO standard : 1. Population 2.Intervention 3.Conditions or disease state 4.Outcomes

8 TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 8 Step 4: Using PICO, define inclusion and exclusion criteria for guidelines or standards Conduct a systematic review of all guidelines or standards relevant to the question Retrieve and review the documents using the inclusion and exclusion criteria Select a preliminary set for analysis Prepare a summary table of standards or guidelines using the PICO format EBD Practice at a Community Health Center

9 TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 9 Step 4: Rate the quality of the guidelines using the GRADE system –Guyatt GH, Oxman AD, Vist G, Kunz R, Falck-Ytter Y, Alonso-Coello P, Schünemann HJ, for the GRADE Working Group. Rating quality of evidence and strength of recommendations GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ EBD Practice at a Community Health Center

10 TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 10 The Grade System

11 TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 11 The GRADE system

12 TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 12 The GRADE system

13 TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 13 Step 6: Decide whether the current guidelines or standards are adequate for your institution or you need to revise them The only change that can be made is not in the evidence, but rather in the conditions which dictate implementation of the guidelines (The C in PICO) –E.g. Your organization may decide to apply topical fluorides based on the risk status of adult patients, if the original evidence supporting the application is based on expert opinion. EBD Practice at a Community Health Center

14 TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 14 Step 6: Disseminate the guideline Train the practitioners to apply the guidelines Conduct calibration exercises using case summaries or patients Monitor the implementation using reviews and chart audits Review and disseminate the findings EBD Practice at a Community Health Center

15 TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 15 Step 4 Revised: If no standards or guidelines are available to answer your PICO question, then search for systematic reviews or the most appropriate evidence to answer the question This process is more time consuming (i.e. more costly) and requires the help of experienced reviewers EBD Practice at a Community Health Center

16 TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 16 Step 5 Revised: Select systematic reviews or primary studies for consideration for further analysis Agree (committee decision) on which studies or reviews will be included in the development of guidelines Summarize the evidence using the PICO format Rate the quality of each bit of evidence using the tools in the ADA EBD website EBD Practice at a Community Health Center

17 TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 17 Appraisal Tools in the EBD Website

18 TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 18 EBD Practice at a Community Health Center While each study should be critiqued for its strengths and weaknesses, decisions on best practices should rely on the best available evidence. In addition to the GRADE system, there are several other classification systems –The most applicable to community health centers, in my opinion, is the one used in the UK National Health Service.

19 TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 19 EBD Practice at a Community Health Center UK National Health Service Level A: Consistent randomized controlled clinical trial, cohort trial, cohort study, … clinical decision rule validated in different populations. Level B: Consistent Retrospective Cohort, Exploratory Cohort, Ecological Study, Outcomes Research, case-control study or extrapolations from level A studies. Level C: Case-series study or extrapolations from level B studies. Level D: Expert opinion without explicit critical appraisal, or based on physiology (or microbiology, biology), bench research....

20 TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 20 EBD Practice at a Community Health Center Step 6 After summarizing and grading the evidence, the panel should decide on how to answer the PICO question: –State the guidance by population group or specific targets –State what are the key points (what, when, and how) for each intervention –Identify conditions when the guidance should be applied (risk factors, patient factors, operator factors) –Define the anticipated outcomes that should be collected, analyzed and followed

21 TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 21 EBD Practice at a Community Health Center Step 7 Disseminate the guidelines, seek comments, and edit the text to clarify it Prepare training of staff to implement the guidelines Define targets for follow-up in implementation Calibrate the providers Assess process and final outcomes Be vigilant for new evidence and modify the guidelines, if necessary Review the application and usability of the guidelines at least once year

22 TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 22 EBD Practice as an Individual Dentist or Dental Hygienist Clinical question Has your institution developed EBD guidelines to answer the question? –If no, search for published guidelines and relevant evidence Critique the evidence using the tools referenced in the previous slides Make a decision on how best to answer the clinical question and strength of evidence supporting your decision Communicate all information: evidence for/against, risks and benefits to the patient Training and calibration of the providers Quality assurance


Download ppt "TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 1 Evidence-based Dental Practice Developing guidelines or clinical recommendations."

Similar presentations


Ads by Google